Transarterial Embolization of Hepatocellular Carcinoma in Hepatitis B Cirrhosis Using Transulnar Approach

Abstract: Recent publications have demonstrated that transradial access is safe and well tolerated in a heterogeneous patient population across a wide range of peripheral vascular interventions. Both the transradial and transulnar approach offer possible advantages in catheterization of intra-abdominal arteries associated with upper extremity antegrade access. We report results of successful transarterial embolization of hepatocellular carcinoma in hepatitis B cirrhosis using a transulnar approach. This report demonstrates that transulnar access was feasible for transarterial oncologic reintervention with no evidence of complication in this singular case. 

Key words: hepatocellular carcinoma, transulnar, transradial

______________________________________________________

We report results of successful transarterial embolization (TAE) of hepatocellular carcinoma (HCC) in hepatitis B cirrhosis using a transulnar approach. In accordance with local institutional guidelines, institutional review board approval was not required for this report. 

Case Presentation

The patient was a 66-year-old male with a history of chronic hepatitis B cirrhosis, prior transarterial chemoembolization (TACE) treatment, and concurrent sorafenib regimen for multifocal HCC who presented to the interventional clinic with mild abdominal pain and MRI findings of enlarging hypervascular hepatic lesions. Post contrast images demonstrated arterial enhancement and interval growth of two lesions within hepatic segments VII and VIII (Figure 1). The patient was status post transfemoral TACE 1 year prior at an outside institution. The patient was noted to have Childs Pugh Score 6, MELD Sodium Score 6, and ECOG status score 0. The patient was subsequently scheduled for TAE as an outpatient based on established efficacy and operator preference. A detailed explanation of the procedure, risks, benefits, alternatives, and potential routes of access were reviewed with the patient and informed written consent was obtained. 

At the time of the procedure, both the radial and ulnar arteries of the left wrist and forearm were evaluated with ultrasound. The radial artery was noted to have diminutive caliber measuring 1.8 mm in diameter. The ulnar artery demonstrated larger caliber and normal course measuring 2.8 mm in diameter (Figure 2). Modified Barbeau and reverse Barbeau screening tests yielded type A waveforms utilizing techniques similar to those described previously.¹ Given patient preference, the differences in size and complete arch inferred from performed tests, the left ulnar artery was selected for access. 

A hydrophilic 5 Fr Glidesheath slender (Terumo Interventional Systems) was placed in the left ulnar artery under ultrasound guidance using a 20 gauge 35 mm needle. Following sheath placement, 2,000 U of heparin, 2.5 mg of verapamil, and 200 mcg of nitroglycerin were administered intra-arterially with hemodilution. Arteriography of the forearm was performed through the sidearm of the sheath demonstrating left ulnar artery with normal caliber and course proximally and confluence at the level of the elbow (Figure 3). A 5 Fr Jacky Radial catheter (Terumo Interventional Systems) and .035˝ glidewire (Terumo Interventional Systems) were advanced into the descending aorta. The superior mesenteric artery was catheterized and subsequent arteriogram demonstrated replaced right hepatic artery with branches supplying the hepatic lesions in segments V and VIII. Selective catheterization was performed utilizing a PROGREAT microcatheter (Terumo Interventional Systems). Selective angiography demonstrated feeding vessel, bifurcation, and tumor blush (Figure 4). The microcatheter was positioned just proximal to the right hepatic segmental bifurcation. One vial of 100 micron to 300 micron Embospheres (Merit Medical) were administered via the microcatheter with stasis achieved at time of completion (Figure 5). Total fluoroscopy time was 11.7 minutes. After removal of catheters and sheath, a TR band (Terumo Interventional Systems) was used for hemostasis at the puncture site and removed after 120 minutes using sequential deflations. No immediate postprocedure complications were noted and the ulnar artery remained patent on Doppler ultrasound prior to discharge. 

At 1 month clinical follow-up, examination of the left radial and ulnar arteries demonstrated palpable pulses. In-office modified Barbeau and reverse Barbeau tests again yielded type A waveforms. The patient’s access site demonstrated no evidence of ecchymosis, hematoma, or pseudoaneurysm formation. No sensory or motor deficiencies were noted. A follow-up MRI with contrast demonstrated stable disease and no enhancement within the previously arterial enhancing lesions.

Discussion

Recent publications have demonstrated that transradial access is safe and well tolerated in a heterogenous patient population across a wide range of peripheral vascular interventions.¹ This approach offers advantages in terms of patient safety and comfort including faster time to ambulation and discharge. 

Literature regarding coronary interventions, specifically the AJULAR trial and recent meta-analysis, has demonstrated that the transulnar approach is not inferior to the transradial when performed by an experienced operator (n=2,532).^2,3 Both the transradial and transulnar approach offer possible advantages in catheterization of intra-abdominal arteries associated with upper extremity antegrade access. At our institution, we perform concurrent assessments of the radial and ulnar arteries when wrist access is considered to optimize procedure performance and technical result. 

Conclusion 

This report demonstrates that transulnar access was feasible for transarterial oncologic reintervention with no evidence of complication in this singular case. Further studies are necessary to evaluate the safety and efficacy of the transulnar approach for peripheral interventions in a greater patient population. 

The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no financial relationships or conflicts of interest regarding the content herein. In accordance with local institutional guidelines, IRB approval was not required for this case report.

Manuscript received June 17, 2016; provisional acceptance given August 1, 2016; manuscript accepted September 2, 2016. 

Address for correspondence: Andrew Kesselman, MD, 450 Clarkson Avenue, Brooklyn, NY 11203. Email: Andrew.Kesselman@downstate.edu

Suggested citation: Suggested citation: Kesselman A, Gallo V, Herskowitz M, Walsh J. Transarterial embolization of hepatocellular carcinoma in hepatitis B cirrhosis using transulnar approach. Intervent Oncol 360. 2016;4(10):E160-E163.

References

1. Poshum R, Biederman DM, Patel RS et al. Transradial approach for noncoronary interventions: a single-center review of safety and feasibility in the first 1500 cases. J Vasc Interv Radiol. 2016;27(2):159-166.
2. Gokhroo R, Kishor K, Ranwa B, et al. Ulnar artery interventions non-inferior to radial approach: AJmer Ulnar ARtery (AJULAR) intervention working group study results. J Invasive Cardiol. 2016;28(1):1-8.
3. Dahal K, Rijal J, Lee J, Korr KS, Azrin M. Transulnar versus transradial access for coronary angiography or percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Catheter Cardiovasc Interv. 2016;87(5):857-865.