An 82-year-old male with cryptogenic cirrhosis presented for locoregional therapy of an HCC detected on recent MRI.
The tumor was a 2.2 cm HCC located in segment 3. The patient was initially treated with QuadraSpheres®(Merit Medical) with no significant response. Given its significant portal shunting related to branch portal invasion (visible on initial angiogram), the decision was made to attempt IRE (Irreversible Electroporation) in this location. Thermal ablation was thought to be potentially less effective given its close proximity to large vascular structures. Pre-IRE angiogram was planned for the purpose of Lipiodol® staining to improve targeting under CT guidance. The Surefire® Infusion System ST device was chosen for infusion to improve Lipiodol uptake in the tumor and to prevent reflux of embolic material into the GDA and right gastric artery.
Bland Lipiodol embolization with Surefire into the LHA for targeting purposes followed by IRE. A 5 French hydrophilic Terumo glide sheath was introduced through the left radial artery. Celiac access was gained with a 5 French Envoy MPD 100cm guide catheter (Codman Neurovascular). The Surefire ST was advanced over a 0.016” Fathom Guidewire (Boston Scientific) to gain access to the left hepatic artery. The Surefire expandable tip was deployed in the left hepatic artery, and 100% of the intended infusion was achieved.
Target vessel diameter
Lipiodol and 900 micron Embozene® Microspheres (CelaNova Biosciences)
An IRE was performed the day after embolization. One month post IRE demonstrated significant lesion necrosis.
Initial HCC identified
Figure 2 A & B
A) Initially treated with Quadraspheres. Note the portal venous filling on angio phase compatible with macrovascular invasion. B) One month follow up CT demonstrates no significant response.
Left radial access was chosen because patient has had both femoral and radial access during previous angiographic procedures and strongly preferred transradial access. Target location for the Surefire device and deployment of the Surefire expandable tip was the left hepatic artery.
Antegrade flow was maintained without any contrast agent reflux. There were no adverse reactions after infusion. Follow up angiogram after completion of drug- eluting bead infusion, demonstrating stasis of flow in the right hepatic artery with maintained perfusion of the left hepatic artery and gastroduodenal artery.
Figure 5 A & B
A) Immediately Post IRE B) One month post IRE arrows point to necrotic lesion.