Transarterial embolization for Hepatic hemangioma
| Indications | 1. Symptomatic large lesions (> 10 cm), causing pain, potential for complications like rupture, or liver function compromise. 2. Kasabach-Merrit syndrome - rapidly growing vascular tumour, thrombocytopenia, microangiopathic haemolytic anaemia and consumptive coagulopathy. 3. Progressive enlargement (>2 cm annual growth) 4. Unresectable lesions with symptoms 5. Patients unfit for surgery |
| Surgery vs. TAE | 1. Surgery is no longer the preferred treatment for multiple or extensive lesions 2. TAE avoids general anaesthesia, has shorter hospital stay, and lower morbidity/mortality rates compared to surgery |
| Choice of Embolization Material (Lipiodol based agents are more effective) | 1. Polyvinyl alcohol (PVA) particles alone (depending on size of feeding vessel 100-300µm, 300-500µm, 500-700µm) 2. Bleomycin with other embolic agents (like PVA and lipiodol) - adding to the sclerosing and embolic effects. Superior to PVA alone. Dose: 30–45 IU Bleomycin mixed with 7–15 ml Lipiodol in a 1:1.5–2 ratio. 3. Pingyangmycin (anti-tumor antibiotic and a vascular sclerosing agent) lipiodol emulsion. Dose: 8–24 mg Pingyangmycin mixed with Lipiodol in 1.5:1 ratio 4. Ethanol |
| Bleomycin (Cautious use due to side effects) | 1. Associated complications include - Sclerosing cholangitis - Interstitial pneumonia - Pulmonary fibrosis 2. Microcatheters improve precise deposition of embolization particles in small feeding arteries (selective and superselective TAE) |
| Mechanism of Action | 1. PVA causes permanent occlusion of hepatic arterioles 2. Lipiodol reduces blood flow temporarily and has tumoricidal activity |
| Complications | 1. Post-Embolization Syndrome (PES) 2. Liver or gallbladder infarction 3. Pneumonia 4. Pleural effusion 5. Transient raised LFTs 6. Hemoglobin drop requiring transfusion |
| Other Management options | 1. Surgical treatment (hepatic resection or enucleation, open, laproscopic or robotic) 2. Ablative therapies 3. Monoclonal antibody 4. Radiotherapy 5. Chemotherapy 6. Radiation therapy and TAE 7. Liver transplantation |
Influence of Blood Supply Type on Interventional Treatment Outcomes in Hepatic Hemangiomas:
| Aspect | Rich Blood Supply | Moderate Blood Supply | Lack of Blood Supply |
|---|---|---|---|
| Thickening of arteries | Mild-to-moderate | Mild | No thickening of arteries. |
| Arterial phase | Abnormal blood sinusoids in the arterial phase. | Abnormal blood sinusoids in the arterial phase. | Few abnormalities in blood-filled sinuses in the arterial phase. |
| Dilatation of number of sinusoidal blood-filled spaces in the parenchymal phase | Majority | Some | 1. Few abnormalities noticed in arterial phase. 2. Presence of paranasal sinus tumors in the parenchymal phase. |
| Treatment Efficacy (within 3 months after embolization) | Higher effectiveness rate (e.g., 18.8%) compared to other types | Lower effectiveness rate (e.g., 8.7%) | Very low effectiveness rate (0%) |
| Safety rates (within 3 months after embolization) | Higher safety rate (e.g., 35.2%) | Lower safety rate (e.g., 21.2%) | No reported safety rate |
| Efficacy | Optimal short-term efficacy of hepatic artery embolization. | Lower short-term efficacy of hepatic artery embolization. | Lack of short-term efficacy of hepatic artery embolization. |
| Complications | Lower incidence of complications, such as liver function reduction, liver abscess, and biliary tract injury (e.g., 5.4%). | Moderate incidence of complications (e.g., 5.7%). | Higher incidence of severe complications (e.g., 18.9%). |
| Fewer complications attributed to chemotherapy drugs and accidental embolization of the biliary ductal system. | Moderate risk of complications due to treatment. | Increased risk of severe complications due to treatment. | |
| Prognosis | Favorable prognosis associated with rich blood supply. | Moderate prognosis with moderate blood supply. | Poor prognosis associated with a lack of blood supply. |
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