Introduction
Transarterial Chemoembolization (TACE) is a minimally invasive, image-guided procedure performed by interventional radiologists to deliver targeted chemotherapy directly to liver tumors, while simultaneously blocking their blood supply.
It is primarily used for unresectable hepatocellular carcinoma (HCC) and certain metastatic liver tumors.
Principle of TACE
The procedure exploits the dual blood supply of the liver:
- Normal liver parenchyma receives 75% of its blood from the portal vein.
- Tumors are primarily fed by the hepatic artery.
By delivering chemotherapeutic agents into the tumor’s arterial supply and then embolizing the artery, TACE:
- Maximizes drug concentration in the tumor.
- Minimizes systemic side effects.
- Causes ischemic necrosis of tumor tissue.
Indications
- Unresectable HCC without main portal vein thrombosis
- Bridging therapy before liver transplantation
- Palliative treatment for advanced HCC
- Select metastatic tumors (neuroendocrine, colorectal)
Contraindications
- Decompensated cirrhosis (Child-Pugh C)
- Severe portal hypertension with uncontrolled ascites
- Complete portal vein thrombosis
- Severe renal dysfunction
- Significant extrahepatic disease
Procedure Steps
- Patient Preparation – Pre-procedure labs, imaging (CT/MRI), informed consent.
- Vascular Access – Usually femoral artery puncture under local anesthesia.
- Selective Catheterization – Use of fluoroscopy to navigate a catheter into the tumor-feeding branch of the hepatic artery.
- Chemotherapy Delivery – Drugs such as doxorubicin, cisplatin, or mitomycin C are mixed with an oily contrast medium (e.g., lipiodol).
- Embolization – Use of gelatin sponge particles or microspheres to block the artery.
- Post-procedure Care – Monitoring for complications, pain management.
Imaging Guidance
- Digital Subtraction Angiography (DSA) – Gold standard for arterial mapping.
- Cone-Beam CT – Enhances tumor visualization and precise drug delivery.
- Ultrasound – Used for access guidance if needed.
Post-Procedure Findings
- Lipiodol retention in tumor on follow-up CT/MRI
- Reduced tumor vascularity on angiographic follow-up
- Gradual tumor shrinkage over months
Complications
- Post-embolization syndrome – Pain, fever, nausea
- Hepatic insufficiency
- Non-target embolization (gallbladder, stomach)
- Rarely, liver abscess or bile duct injury
Outcomes
- Increased survival in intermediate-stage HCC (BCLC stage B)
- Better quality of life compared to systemic therapy in select cases
- Effective as bridging therapy before liver transplant
Future Directions
- DEB-TACE (Drug-Eluting Bead TACE) – Controlled drug release for prolonged tumor exposure
- Combination therapy with immunotherapy and systemic agents
- Radiomics and AI for patient selection and response prediction
Key Takeaways
- TACE is the mainstay of treatment for intermediate-stage unresectable HCC.
- It offers targeted drug delivery with minimal systemic toxicity.
- Success depends on careful patient selection and meticulous technique.
