Immediate and delayed complications of transarterial chemoembolization with drug-saturable microspheres in unresectable liver tumors

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Abstract

Backgraund: For many years of world experience in the use of transarterial chemoembolization (TACE) on liver tumors, data have appeared on immediate and delayed complications, which, however, represent a description of clinical observations or literature reviews compiled on their basis. There are currently no systematic studies that study the timing of complications and risk factors.
Aims: to evaluate immediate and delayed complications of transarterial chemoembolization with drug-saturable microspheres in the treatment of unresectable malignant liver tumors.
Materials and methods: A retrospective observational uncontrolled study that included 75 patients with unresectable liver disease (65 patients with metastases, 10 patients with primary malignant tumors) who underwent 102 transarterial chemoembolizations with drug-saturable microspheres. The antitumor effect of TACE was assessed according to abdominal computed tomography (CT) and magnetic resonance imaging of the hepatobiliary zone (MRI) with intravenous contrast, performed within a limited time frame: no later than 2 weeks before (control 0), after 8–9 weeks (control 1) and 16–17 weeks after TACE (control 2). In the event of complications, diagnostic studies were performed as clinically necessary.
Results: 3 patients developed lesions of the biliary tree. The process began on days 2–11 after TACE with dilatation of the bile ducts in single segments; changes in 2–3 weeks took on a bilobar character, leading to the formation of bilomas (2 patients) and necrosis of the periductal liver parenchyma (1 patient). Before TACE, all three patients underwent bile duct stenting due to existing biliary hypertension. Two patients developed pancreatitis 1–2 weeks after TACE; at the same time, there were no features of vascular anatomy, non-target embolization. In 17 patients after 2-4 months after TACE according to CT and MRI, the phenomena of cholecystitis were noted. The changes were asymptomatic, leading to the formation of small stones in the gallbladder lumen after 6–10 months.
Conclusions: The immediate complications of TACE with drug-saturated microspheres (1-3%) in the treatment of unresectable liver tumors are associated with the pathology of the bile ducts and pancreas, appear in the first month, have a staging, affect the somatic condition of patients and require specific treatment. Long-term complications (23%) are associated with the reaction of the gallbladder, develop after a few months, while they are asymptomatic and do not require correction.

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Transarterial chemoembolization (TACE) is an endovascular operation that has become an alternative treatment option for unresectable malignant liver lesions: since 2018, the method has been included in the treatment regimen for hepatocellular cancer; since 2021, the indications have expanded to include intrahepatic cholangiocarcinoma, metastatic colorectal and neuroendocrine cancer [1– 4]. At the same time, there are works on the successful use of the method in the treatment of liver metastases in breast cancer and rare tumors of other locations [5, 6].
One of the options for transarterial chemoembolization is the use of drug-saturated microspheres. They are able to absorb a chemotherapy solution, increasing their volume tens of times; when introduced into the afferent vessels of the tumor, the microspheres clog them, and the cytostatic is released directly into the lesion within 2–3 weeks. The microspheres themselves decrease in volume and leave the vascular bed [7, 8]. Thus, the operation procedure involves two damaging factors: the effect on the arterial vessels and the long-term supply of cystostatic.
Over many years of global experience in the use of transarterial interventions on liver tumors, data have emerged on immediate and delayed complications, which, however, represent a description of clinical observations or literature reviews compiled on their basis, without taking into account the technical features of the operation and premorbid background [9, 10, 11] . There are currently no systematic studies examining the timing of complications and their risk factors.
TARGET
to evaluate immediate and delayed complications of transarterial chemoembolization with drug-loaded microspheres in the treatment of unresectable malignant liver tumors.

METHODS
Study design
A retrospective observational uncontrolled study was conducted that included patients with unresectable liver disease: 65 with metastases (group 1), 10 with primary malignant tumors (group 2). 102 transarterial chemoembolization operations with drug-saturated microspheres were performed: 65 primary and 22 repeated in group 1, 10 primary and 5 repeated in group 2. The antitumor effect of TACE was assessed using computed tomography (CT) of the abdominal cavity (diagnostic protocol 1) and magnetic resonance imaging (MRI) of the hepatobiliary zone (diagnostic protocol 2) with intravenous contrast, performed within a strictly limited time frame: no later than 2 weeks before (control 0), 8–9 weeks (control 1) and 16–17 weeks after TACE (control 2). If complications occurred, these diagnostic studies were carried out as clinically necessary, but the antitumor effect of the operation on them was not assessed.
The study design is presented in Fig. No. 1.

Inclusion criteria for the study were:
1) histologically verified malignant liver tumors;
2) unresectable liver disease;
3) performing a diagnostic protocol (CT and/or MRI) no later than 14 days before TACE;
4) compliance with the timing of control studies: 8–9 weeks, 16–17 weeks after TACE.
5) the minimum observation period after TACE is 3 months.
Exclusion criteria were:
1) the patient’s refusal to undergo TACE surgery;
2) failure to comply with the deadlines for control examinations;
3) follow-up less than 3 months;
4) previous transarterial effect on the liver in the form of chemoinfusion, embolization of the hepatic arteries.
Patients were included in the study from the moment the decision was made to perform TACE and signed a voluntary informed consent for the operation.
Initially, all patients were scheduled for one TACE procedure. Repeated operations were performed in patients who responded to therapy when the process progressed.

Conditions
Transarterial chemoembolization operations with drug-saturated microspheres were performed at the Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies of the Federal Medical and Biological Agency of Russia (Moscow) by one x-ray surgeon.
Diagnostic studies were carried out in centers of the FMBA system of Russia, as well as at the place of residence of patients with remote consultation of the results by one radiologist.
Treatment of patients before and after TACE was carried out at the Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies of the Federal Medical and Biological Agency of Russia (Moscow), the Federal State Budgetary Institution National Medical Research Center named after. acad. E.N. Meshalkin Ministry of Health of the Russian Federation" (Novosibirsk), clinical medical center of the Moscow State Medical and Dental University named after A.I. Evdokimov (Moscow), as well as oncological institutions at the place of residence of patients.

Duration of the study
Recruitment of patients was carried out from September 2017 to January 2023, dynamics were monitored for June 2023.

Description of medical intervention
Transarterial chemoembolization with drug-saturated microspheres was performed in cath labs equipped with stationary angiographic units and anesthesiological equipment, equipped with workstations for an operating room and an anesthesiological nurse. All operations were performed on the angiographic complex “Innova 3100 IQ” (General Electric, USA) and “Allura Centron” (Philips, the Netherlands), which are equipped with flat-panel digital detectors with a diagonal of 15 inches and a set of specialized programs: recording was used to visualize intraorgan vessels of small caliber angiograms in DSA mode (Digital Subtraction Angiography, English – digital subtraction angiography), with the ability to select the level of subtraction (“Landmark” mode). To facilitate selective catheterization of the target vessel in complex x-ray anatomical areas and when passing through tortuous vessels, the “Roadmap” fluoroscopic mode was used.
To provide access to the arterial vascular bed, the right radial artery (67 operations, 66%), left radial artery (20 operations, 20%), and right ulnar artery (15 operations, 14%) were used. The femoral, brachial, and axillary arteries were not used.
For chemoembolization, microspheres “HepaSphere” (MeritMedical, USA) and “Sphere-Spectrum” (LLC “Sphere-Spectrum”, Russia), saturated with doxorubicin or irinotecan (depending on the histological type of tumor), with working sizes of 200-400 microns were used. To search for tumor afferents, arteriography was performed, the data of which were compared with diagnostic studies (CT and MRI). The chemoembolization procedure was performed segment by segment by catheterizing the tumor arteries with a microcatheter and administering drug-saturated microspheres until the control point was reached. To confirm tumor treatment and completion of chemoembolization, control arteriographies were performed in all patients. The TACE procedure was carried out under the control of the general condition of the patient, including monitoring of heartbeat, pulse and blood pressure. Before surgery, all patients were premedicated with sedatives.
Main outcome of the study
The study assessed “true” endpoints in the form of complications recorded on diagnostic studies (CT or MRI). The analysis included a comparison with the premorbid background, previous treatment, technical aspects of TACE, and anatomical features of the vascular bed.
Additional study outcomes
The antitumor effect of TACE was assessed using a “surrogate” end point - the total volume of tumor lesions in the liver, which was calculated using CT or MRI data.

Subgroup analysis
Liver metastases in group 1 of patients (n=65) were represented by colorectal cancer (n=40), neuroendocrine cancer (n=10), and adenocarcinomas of various locations (n=15). In 30 patients, the liver was the only affected target organ, in 35 it was combined with metastatic damage to the bones, lungs, lymph nodes, and spleen. In 42 patients the primary lesion was removed, in 23 it was not removed.
In group 2 (n=10), 8 patients had hepatocellular cancer, 2 had intrahepatic cholangiocarcinoma. In 5 patients, hepatocellular cancer developed against the background of liver cirrhosis, in 3 patients the liver was cirrhotic. Intrahepatic cholangiocarcinoma developed in the intact liver in 2 patients.
Within each subgroup, there were patients in whom TACE was performed immediately upon detection of liver damage and those in whom TACE was performed during progression during antitumor treatment.

Methods for recording outcomes
To record the main and additional outcomes of the study, computed tomography and magnetic resonance imaging were used, the methods for performing which are reflected in the recommendations of professional societies [12], and the timing was regulated by the study design.
When analyzing the main outcomes, angiography, CT and MRI were compared with clinical and anamnestic data.

Ethical review
The TACE protocol was approved by the Ethics Committee of the Federal State Budgetary Institution “Moscow State Medical and Dental University named after. A.I. Evdokimov”, protocol 83-DK-s-I dated 06.23.2017, and also approved at a meeting of the Academic Council of the FSBI “Moscow State Medical and Dental University named after. A.I. Evdokimov" of the Ministry of Health of the Russian Federation dated December 12, 2017, protocol No. 5.

Statistical analysis
Principles for sample size calculation: The sample size was not pre-calculated.
Methods of statistical data analysis: the material was processed statistically according to generally accepted methods described in the work of S. Glanz (1999), using the Statistica 10.0 software package (Stat-Soft, 2011). The normality of distribution of quantitative variables was checked using the Shapiro-Wilk test. Since the distribution of variables was different from normal, nonparametric methods were used during the analysis. For quantitative variables, medians and quartiles were calculated.

RESULTS
Objects (participants) of the study
Clinical characteristics of patients of groups 1 and 2, obtained from medical records, are presented in Table No. 1.
Main results of the study
3 patients developed damage to the biliary tree. The process began on days 2–11 after TACE and looked like a sharp local dilatation of the bile ducts in single segments, detected on CT and MRI. Over the course of 21 days, the changes progressed, involving new segments and becoming bilobar in nature. At the same time, in addition to locally dilated bile ducts, in 2 patients delimited intrahepatic fluid accumulations with heterogeneous contents (bilomas) began to form, and in 1 patient necrosis of the periductal liver parenchyma developed (Fig. No. 2).
These changes were accompanied by a rise in body temperature to 38–39 degrees, nausea and vomiting, pain in the right hypochondrium, an increase in the level of liver enzymes and bilirubin by 5–10 times; in all cases, specific treatment was required, including surgical drainage of fluid collections.
All three patients underwent bile duct stenting before TACE due to existing biliary hypertension; 2 patients had previously undergone resection of liver metastases; all patients received courses of chemotherapy. Among patients who had previously undergone bile duct plastic surgery, but without stenting and biliary hypertension, there were no such complications.
One patient developed edematous pancreatitis 2 days after TACE, and 1 patient 14 days later developed acute interstitial pancreatitis with fluid accumulations in the peripancreatic tissue, which was identified by computed tomography. These changes were accompanied by an increase in the level of amylase in the blood, nausea and vomiting, pain in the right hypochondrium and epigastrium.
When compared with angiography data, the vascular anatomy of the celiac trunk and its branches was typical; no disturbances in the patency of the great vessels in the TACE zone were recorded (Fig. No. 3). With conservative therapy, as well as surgical drainage of fluid accumulations, the symptoms of pancreatitis were stopped.
In both patients, the primary lesion was located near the liver vessels (adenocarcinoma of the transverse colon, ascending colon); patients repeatedly received courses of chemotherapy after surgical removal of the primary lesion. No risk factors associated with vascular anatomy and the technical course of TACE were identified.
15 patients of group 1 (23%), 2 patients of group 2 (20%) had cholecystitis. It was diagnosed on CT and MRI 8–16 weeks after TACE and appeared as lamination and thickening of the gallbladder wall. These changes were an incidental finding and did not affect the somatic condition; when observed over time after 6-10 months. in half of the patients (n=9) small stones formed in the lumen of the gallbladder (Fig. No. 4).
In 21 patients with gallbladder stones present before TACE, no change in condition was noted after surgery. In 11 patients, during the first year after TACE, small stones appeared in the lumen of the gallbladder, without changes in its walls.

Additional Study Findings
After two TACE controls, 51 patients (79%) responded to treatment, which was reflected in a decrease in the total volume of tumor lesions in the liver. 14 patients (21%) did not respond to treatment because they experienced an increase in the total volume of affected liver parenchyma and the appearance of fresh metastases.


Adverse events
After TACE, symptoms of post-embolization syndrome (nausea, low-grade fever, pain in the right hypochondrium) were observed, which required symptomatic therapy and resolved within 1–3 days.
DISCUSSION
Summary of the main finding of the study
According to our data, the immediate complications of TACE, which appeared in the first 2 weeks after surgery, were associated with damage to the bile ducts and the reaction of the pancreas and required specific treatment. Risk factors included stenting of the bile ducts as an indicator of existing problems in the biliary tree, as well as surgical interventions near the vessels of the liver and pancreas.
Long-term complications that developed after 2–4 months. after TACE, were expressed in the phenomena of cholecystitis and were an accidental finding; no risk factors were identified.

Discussion of the main result of the study
Complications of transarterial interventions on the hepatic arteries are currently being actively discussed among experts. This is primarily due to the potential negative impact on the parabiliary choroid plexuses that supply the walls of the bile ducts [13].
I. Sakamoto in his study identifies two factors: 1) direct blockage of the parabiliary plexuses; 2) stenosis of the bile duct due to ischemia, causing stagnation of bile and its leakage into the surrounding tissues [14].
This stage of toxic-ischemic cholangitis manifests itself on diagnostic studies in the form of local dilation of the intrahepatic bile ducts and has different names: branched biloma, dilatation of the bile ducts with extravascular accumulation of bile along the portal tract [15, 16]. Sometimes this pathology is mistakenly regarded as biliary hypertension, which requires comparison with bilirubin values [14].
Even after cessation of transarterial exposure, obstruction of the adjacent branch of the portal vein and liver necrosis develop in 90% of cases due to the chemical aggressiveness of bile [17, 18]. Moreover, changes may not appear immediately. S. Kobayashi, according to autopsy data, showed that necrosis of the bile ducts after TACE for hepatocellular cancer develops in 9% of cases [17]. S. Phongkitkarun indicates that pathology of the bile ducts after intra-arterial chemoinfusion occurs in 57%, and develops 1–12 months after treatment [19].
In the presented study, we encountered pathology of the biliary tree that developed in the immediate period after TACE and manifested itself as local dilation of the bile ducts, the formation of bilomas and periductal necrosis of the liver parenchyma. Note that the changes were clearly staged, although it was not possible to prevent their progression. Moreover, all patients had a common risk factor – biliary hypertension, which required stenting of the bile ducts. This aspect, in our opinion, should be taken into account when selecting patients for transarterial interventions on the hepatic arteries.
Delayed complications in the form of cholecystitis, which occurred in every fifth patient in our study, are most likely the result of a combination of microcirculation disorders and the toxic effect of the cytostatic; however, due to the low intensity of exposure to these factors, compensatory mechanisms have time to work without leading to fatal consequences for the patient.
Another potentially dangerous complication of TACE is pancreatitis, but not all cases are clinically evident. K. Khan and colleagues noted back in 1993 that in 40% of patients after non-selective lobar chemoembolization of hepatocellular cancer with lipiodol, the level of pancreatic enzymes asymptomatically increased [20]. The incidence of symptomatic acute pancreatitis after TACE ranges from 2 to 4% [21, 22]. However, the key risk factors have not yet been identified.
In our study, symptomatic pancreatitis developed in 2 patients and manifested itself within the next 2 weeks. Since there were no signs of non-target embolization and features of vascular anatomy, even despite previous surgical treatment, it can be assumed that the complication is of a toxic-ischemic nature due to the two-component effect of TACE and, in fact, is multifactorial.
The data available in the literature on the 1.4%-7.4% incidence of liver abscesses after chemoembolization with microspheres was not confirmed in our study, which is probably due to the timely diagnosis of complications and the prevention of infectious processes [23].

Limitations of the study
A limitation of the study is its retrospective nature and the lack of a control group. At the same time, complications of TACE have been studied in histologically heterogeneous liver tumors, at different stages of the disease and with different survival prognosis, which increases the reproducibility of the results in other clinical groups.
CONCLUSION
Thus, transarterial chemoembolization with drug-loaded microspheres in the treatment of unresectable liver tumors has immediate and delayed complications. Immediate complications are rare (1–3%), associated with pathology of the bile ducts and pancreas, appear in the first month, affect the somatic condition of patients and require specific treatment. In this case, biliary hypertension is a clear risk factor.
Long-term complications are common (23%), associated with the reaction of the gallbladder, develop several months after surgery, do not affect the somatic condition of patients and do not require correction.
The identified complications, taking into account the timing of onset and severity of clinical manifestations, are most likely a consequence of the two-component antitumor mechanism of TACE, which should be taken into account during dynamic monitoring of such patients.

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About the authors

Elena Aleksandrovna Zvezdkina

State Scientific Center for Laser Medicine of Federal Medical and Biology Agency

Email: zvezdkina@yandex.ru
ORCID iD: 0000-0002-0277-9455

Ph.D., Researcher at the Department of Ambulatory Laser Medicine

Russian Federation, 40, Studencheskaya str., Moscow, 121165, Russian Federation

Anna Genrikhovna Kedrova

Federal Research Clinical Center for Specialized Types of Health Care and Medical Technologies of Federal Medical and Biology Agency; Academy of Postgraduate Education, Federal Research and Clinical Center for Specialized Medical Care and Medical Technologies, Federal Medical and Biological Agency of the Russian Federation

Email: kedrova.anna@gmail.com
ORCID iD: 0000-0003-1031-9376
SPIN-code: 3184-9760

M.D., Professor, Head of the Department of Obstetrics and Gynecology; Head of the Department of Oncology; chief oncologist

Russian Federation, 28, Orekhovy Boulevard str.,Moscow, 115682, Russian Federation; 91, Volokolamskoe Shosse, Moscow, 125371,Russian Federation

Dmitry Petrovich Lebedev

Federal Research Clinical Center for Specialized Types of Health Care and Medical Technologies of Federal Medical and Biology Agency

Email: lebedevdp@gmail.com
ORCID iD: 0000-0003-1551-3127
SPIN-code: 4770-5722

doctor for X-ray endovascular diagnostics and treatment

Russian Federation, 28, Orekhovy Boulevard str.,Moscow, 115682, Russian Federation

Dmiry Nikolaevich Panchenkov

Evdokimov Moscow State University of Medicine and Dentistry

Email: dnpanchenkov@mail.ru
ORCID iD: 0000-0001-8539-4392
SPIN-code: 4316-4651

M.D., Professor, Head of the Laboratory of Minimally Invasive Surgery

Russian Federation, 20/1, Delegatskaya str., Moscow, 127473, Russian Federation

Dmitry Anatolievich Аstakhov

Evdokimov Moscow State University of Medicine and Dentistry

Email: astakhovd@mail.ru
ORCID iD: 0000-0002-8776-944X
SPIN-code: 6203-5870

Ph.D., Senior Researcher

Russian Federation, 20/1, Delegatskaya str., Moscow, 127473, Russian Federation

Yulia Aleksandrovna Stepanova

Vishnevsky National Medical Research Center for Surgery

Author for correspondence.
Email: stepanovaua@mail.ru
ORCID iD: 0000-0002-2348-4963
SPIN-code: 1288-6141

M.D., Professor, Scientific Secretary

Russian Federation, 27, Bolshaya Serpukhovskaya str., Moscow, 115093, Russian Federation

References

  1. Association of Oncologists of Russia, Interdisciplinary Society of Specialists in Liver Tumors, All-Russian Public Organization "Russian Society of Clinical Oncology", All-Russian Public Organization for the Promotion of Radiation Diagnostics and Therapy "Russian Society of Radiologists and Radiologists". Liver cancer (hepatocellular). Clinical recommendations of the Russian Federation - 2022.
  2. Vogel A, Cervantes A, Chau I, Daniele B. Hepatocellular carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology. 2018; 29(4):238–255. doi: 10.1093/annonc/mdy
  3. Lucatelli P, Burrel M, Guiu B. CIRSE Standards of Practice on Hepatic Transarterial Chemoembolisation. Cardiovasc Intervent Radiol. 2021; 44: 1851–1867 doi: 10.1007/s00270-021-02968-1.
  4. Yoshino T, Cervantes A, Bando H. Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with metastatic colorectal cancer. ESMO Open. 2023; 8(3): doi: 10.1016/j.esmoop.2023.101558
  5. Wang M, Zhang J, Ji S, Shao G. Transarterial chemoembolisation for breast cancer with liver metastasis: A systematic review. Breast. 2017; 36: 25-30. doi: 10.1016/j.breast.2017.09.001.
  6. Adam L, Savic L, Chapiro J. Response assessment methods for patients with hepatic metastasis from rare tumor primaries undergoing transarterial chemoembolization. Clin Imaging. 2022; 89: 112-119. doi: 10.1016/j.clinimag.2022.06.013.
  7. De Baere T, Plotkin S, Yu R, Sutter A. An in vitro evaluation of four types of drug-eluting microspheres loaded with doxorubicin. J Vasc Interv Radiol. 2016; 27(9):1425-1431. doi: 10.1016/j.jvir.2016.05.015.
  8. Kennoki N, Saguchi T, Sano T. Long-term histopathologic follow-up of a spherical embolic agent; observation of the transvascular migration of HepaSphere TM. BJR Case Rep. 2019; 5(1):20180066. doi: 10.1259/bjrcr.20180066.
  9. Lee HN, Hyun D. Complications related to transarterial treatment of hepatocellular carcinoma: a comprehensive review. Korean J Radiol. 2023; 24(3):204-223. doi: 10.3348/kjr.2022.0395.
  10. Carling U, Dorenberg EJ, Haugvik SP. Transarterial chemoembolization of liver metastases from uveal melanoma using irinotecan-loaded beads: treatment response and complications. Cardiovasc Intervent Radiol. 2015; 38(6):1532-41. doi: 10.1007/s00270-015-1093-4.
  11. Singh BN, Zangan SM. Hepatocellular carcinoma rupture following transarterial chemoembolization. Semin Intervent Radiol. 2015; 32(1):49-53. doi: 10.1055/s-0034-1396964.
  12. CT/MRI LI-RADS® v2018 Technical Recommendations. https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/LI-RADS/LI-RADS-CT-MRI-v2018 (доступно 06.09.2023)
  13. Gaudio E, Franchitto A, Pannarale L. Cholangiocytes and blood supply. World J. Gastroenterol. 2006; 12:3546–3552. doi: 10.3748/wjg.v12.i22.3546.
  14. Sakamoto I, Iwanaga S, Nagaoki K. Intrahepatic biloma formation (bile duct necrosis) after transcatheter arterial chemoembolization. Am. J. Roentgenol. 2003; 181:79–87. doi: 10.2214/ajr.181.1.1810079.
  15. Zhang B, Guo Y, Wu K, Shan H. Intrahepatic biloma following transcatheter arterial chemoembolization for hepatocellular carcinoma: Incidence, imaging features and management. Mol. Clin. Oncol. 2017; 6:937–943. doi: 10.3892/mco.2017.1235.
  16. Spina J, Hume I, Pelaez A. Expected and unexpected imaging findings after 90Y transarterial radioembolization for liver tumors. Radiographics. 2019; 39(2):578-595. doi: 10.1148/rg.2019180095.
  17. Kobayashi S, Kozaka K, Gabata T. Pathophysiology and imaging findings of bile duct necrosis: a rare but serious complication of transarterial therapy for liver tumors. Cancers. 2020; 12(9): 2596. doi: 10.3390/cancers12092596
  18. Yu J., Kim K. W., Park M. S. et al. Bile duct injuries leading to portal vein obliteration after transcatheter arterial chemoembolization in the liver: CT findings and initial observations. Radiology. 2001; 221:429–436. doi: 10.1148/radiol.2212010339.
  19. Phongkitkarun S, Kobayashi S, Varavithya V. Bile duct complications of hepatic arterial infusion chemotherapy evaluated by helical CT. Clin. Radiol. 2005; 60:700–709. doi: 10.1016/j.crad.2005.01.006.
  20. Khan K, Nakata K, Shima M. Pancreatic tissue damage by transcatheter arterial embolization for hepatoma. Dig Dis Sci. 1993; 38(1):65–70. doi: 10.1007/BF01296775
  21. Tan Y, Sheng J, Tan H. Pancreas lipiodol embolism induced acute necrotizing pancreatitis following transcatheter arterial chemoembolization for hepatocellular carcinoma: A case report and literature review. Medicine (Baltimore). 2019; 98(48):e18095. doi: 10.1097/MD.0000000000018095
  22. Yamaguchi T, Seki T, Komemushi A. Acute necrotizing pancreatitis as a fatal complication following DC Bead transcatheter arterial chemoembolization for hepatocellular carcinoma: A case report and review of the literature. Mol Clin Oncol. 2018; 9(4):403-407. doi: 10.3892/mco.2018.1690
  23. Toro A, Bertino G, Arcerito M. Lethal complication after transarterial chemoembolization with drug-eluting beads for hepatocellular carcinoma. Hindawi Publishing Corporation. Case Reports in Surgery. 2015; 1: 6. doi: 10.1155/2015/873601

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Copyright (c) 2023 Zvezdkina E.A., Kedrova A.G., Lebedev D.P., Panchenkov D.N., Аstakhov D.A., Stepanova Y.A.

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