Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma in Patients with Celiac Axis Occlusion Using Pancreaticoduodenal Arcade As a Challenging Alternative Route

Introduction: Celiac axis occlusion is a challenging condition when catheterization of the hepatic artery is required for chemoembolization of hepatocellular carcinoma (HCC). As a result, the hepatic artery has to be catheterized through the pancreaticoduodenal arcades (PDA) and the gastroduodenal artery (GDA) from the superior mesenteric artery (SMA) which is a tortuous course with acute angles and small caliber branches. Objective: To assess new techniques for facilitating catheterization of the tortuous PDA and the GDA to reach the proper hepatic artery (PHA) and tumor-feeding branches in patients with celiac axis occlusion undergoing chemoembolization of HCC. Methods and materials: The study included eleven patients all admitted to do transcatheter arterial chemoembolization (TACE) for treatment of unresectable HCC. During angiography occlusion of the celiac axis was diagnosed and hypertrophied PDA and GDA was noted in SMA angiography. Catheterization of the PDA was performed by preshaping of the micro-guide wire into a wide curve. Catheterization of the PHA was a challenge and was achieved by reshaping of the micro-guide wire or by looping technique. TACE was done after super selective catheterization of the tumor feeding artery using a mixture of 50 mg of adriamycin, 7cc of lipiodol and gelfoam. Results: In the eleven patients with celiac artery occlusion, DSA showed complete celiac axis occlusion in all patients. Collateral arteries supplying the liver were readily evident via PDA and GDA from SMA. Successful catheterization of the PHA was achieved in all patients. Chemoembolization was performed to all patients after super selective catheterization of the feeding artery. Follow-up triphasic CT was performed in all patients, 9 patients showed good lipiodol trapping with no residual tumor enhancement. Two patients required another session of TACE. Conclusion: Chemoembolization of HCC through the PDA and the GDA using micro-guide wire preshaping technique and the microcatheter looping technique in patients with celiac axis occlusion is a challenging but effective treatment for HCC.