Hepatic artery embolization chemotherapy 1. Basic principles. (1) It is required to be performed under digital subtraction angiography machine; (2) Clinical indications must be strictly mastered; (3) Standardization and individualization of treatment must be emphasized. 2. Applicable groups. (1) Patients with intermediate and advanced primary liver cancer who cannot be surgically resected: (2) Patients who can be surgically resected but cannot or do not want to undergo surgery due to other reasons (such as advanced age, severe cirrhosis, etc.). For the above patients, interventional therapy can be the preferred method among non-surgical treatments. Domestic clinical experience shows that hepatic artery intervention is effective for giant hepatocellular carcinoma with relatively intact envelope and large hepatocellular carcinoma, but for hepatocellular carcinoma that can be surgically resected, surgical resection is preferred. The main influencing factors of interventional therapy are: ① serum AFP level; ② whether the tumor lesion has intact envelope and clear boundary; ③ whether there is cancer thrombus in portal vein. 3. Indications. (1) The main indications for TACE are: (1) middle to advanced HCC that cannot be surgically resected, without serious liver and kidney dysfunction, including: (1) massive hepatocellular carcinoma: the proportion of tumor in the whole liver is less than 70%; (2) multiple nodular hepatocellular carcinoma; (3) the main trunk of portal vein is not completely obstructed, or although completely obstructed, compensatory collateral vessels between hepatic artery and portal vein are formed; (4) those who failed in surgery or recurred after surgery; (5) liver function classification (Child-Pugh) A or B; and (6) the liver function of the tumor. Child-Pugh) grade A or B, ECOG score 0-2; (6) ruptured hepatic tumor bleeding and portal hypertensive bleeding caused by hepatic artery – portal vein static shunt. (2) It is applied before resection of liver tumor, which can shrink the tumor and facilitate the second stage resection, and at the same time can clarify the number of lesions; (3) Small hepatocellular carcinoma, but not suitable or unwilling for surgery, local radiofrequency or microwave ablation treatment; (4) Control of local pain, bleeding and embolization of arteriovenous impotence; (5) After resection of hepatocellular carcinoma, to prevent recurrence. 4. Contraindications. (1) severe impairment of liver function (Child-Pugh grade C); (2) severely reduced coagulation function that cannot be corrected; (3) portal vein trunk completely embolized by cancer embolism and little formation of collateral vessels; (4) combined with active infection and cannot be treated simultaneously; (5) extensive distant metastasis of tumor and estimated survival <3 months; (6) cachexia or multi-organ failure; (7) (7) Tumor occupying ≥70% of the whole liver; if the liver function is basically normal, a small amount of iodine oil emulsion can be considered for fractional embolization; (8) Significant reduction of peripheral blood leukocytes and platelets, leukocytes <3,0×109/L (not absolutely contraindicated, such as hypersplenism, different from chemotherapeutic leukopenia), platelets <60×109/L. Embolization is applied before resection of liver tumor, which can make the tumor shrink and facilitate resection. It can also clarify the number of lesions and control metastasis No severe liver and kidney dysfunction, no complete obstruction of the main portal vein, tumor occupancy less than 70% Failure of surgical procedures or recurrence after resection Control of pain, bleeding and arteriovenous fistula Prophylactic hepatic artery chemoembolization after resection of hepatocellular carcinoma Recurrence of hepatocellular carcinoma after liver transplantation Severe hepatic dysfunction, Child-Pugh grade C Severely reduced coagulation, and (If liver function is basically normal, super-selective catheter technique can be used to embolize the tumor target vessels in stages) Infection, such as liver abscess Extensive metastasis throughout the body, and it is estimated that treatment cannot prolong the patient's survival Systemic failure Cancer occupying 70% or more of the whole liver (If liver function is basically normal, a small amount of iodine oil can be used for embolization in stages) (If the liver function is basically normal, a small amount of iodine oil can be used for embolization in stages) 5. Basic operation: hepatic arteriography, usually using the Seldinger method, percutaneous puncture femoral artery cannulation, catheter placed in the abdominal trunk or common hepatic artery imaging, imaging image acquisition should include the arterial phase, parenchymal phase and venous phase; superior mesenteric arteriography should be done, pay attention to the search for collateral blood supply. (1) Hepatic artery infusion chemotherapy (TAI): After careful analysis of the imaging performance, the site, size, number and blood supply artery of the tumor are clarified, super-selective intubation into the blood supply artery of the tumor is performed to give infusion chemotherapy, and the commonly used chemotherapeutic drugs are adriamycin (ADM) or epi-adriamycin (EADM), cisplatin (PDD), 5-fluorouracil (5-Fu), hydroxycitrulline (HCP), and hepatic artery (HCP). Hydroxycamptothecin (HCPT) and mitomycin (MMC). (2) Hepatic artery embolization (TAE): commonly used clinically, super-selective cannulation should be adopted whenever possible, and attention should be paid to the selection of appropriate embolic agents. The amount of iodine oil should be controlled according to the size of tumor, blood supply and the number of tumor blood supplying arteries, and other embolic agents such as gelatin sponge, permanent particles and microspheres can also be used. For hepatocellular carcinoma combined with arteriovenous fistula, it should be noted that firstly, the arteriovenous fistula should be effectively embolized and blocked, and then TAE for tumor should be performed to prevent serious complications such as pulmonary embolism and to ensure the effect of anti-tumor TAE; for severe arteriovenous fistula, it is generally advocated to take TAI treatment only. (3) Hepatic artery embolization chemotherapy (TACE): Hepatic artery infusion chemotherapy (TAI) and hepatic artery embolization (TAE) are performed simultaneously to improve the efficacy. TACE can effectively block the arterial blood supply of hepatocellular carcinoma, while releasing high concentrations of chemotherapeutic drugs to combat the tumor, causing ischemic necrosis and shrinkage, with less impact on normal liver tissue. Evidence-based medical evidence has shown that TACE can effectively control the growth of hepatocellular carcinoma, significantly prolong the survival of patients, and benefit patients with hepatocellular carcinoma, which has become the first and most effective treatment method for middle and advanced hepatocellular carcinoma that cannot be surgically resected. Before TACE, we should analyze the imaging performance, clarify the tumor site, size, number and blood supplying artery, and then super-select the cannula to the right hepatic artery and left hepatic artery to give perfusion chemotherapy respectively. The head end of the catheter should cross the gallbladder, the right gastric artery and the gastroretinal artery and other vessels. In most HCC, more than 95% of the blood supply comes from the hepatic artery, which is characterized by thickened blood supply arteries, abundant tumor vessels and dense tumor staining. Embolization should be performed after perfusion chemotherapy. It is advocated that super-liquefied ethyl iodide oil and chemotherapeutic drugs should be fully mixed into an emulsion, and the mixture should be slowly injected into the target vessel through a microcatheter super-selectively inserted into the blood supplying arterial branch of the tumor. Embolization should be performed to avoid embolization of normal liver tissue or into non-target organs. For patients with hepatocellular carcinoma with markedly thickened blood supply arteries, it is usually advisable to add granular embolic agents (e.g. gelatin sponge or microspheres) after the iodine oil emulsion embolization. Embolization should try to embolize all the feeding vessels of the tumor in order to de-vascularize the tumor. Care should be taken not to completely occlude the intrinsic hepatic artery to facilitate re-TACE treatment. The main factors affecting the long-term efficacy of TACE include the degree of cirrhosis, the functional status of the liver and the tumor condition (size, grade, pathological type, portal vein carcinoma thrombus, and arteriovenous fistula). In addition, TACE treatment itself has some limitations, which are: (1) TACE is often difficult to achieve complete necrosis due to incomplete embolization and establishment of tumor collateral vessels; (2) after TACE treatment, the level of hypoxia-inducible factor (HIF) in the residual tumor increases due to ischemia and hypoxia of the tumor tissue, resulting in high expression of vascular endothelial growth factor (VEGF). These factors can lead to intrahepatic tumor recurrence and distant metastasis. 6. Common adverse effects after TACE. Post-embolization syndrome is the most common adverse effect of TACE treatment, mainly manifested as fever, pain, nausea and vomiting. Fever and pain occur because of local tissue ischemia and necrosis caused by embolization of hepatic artery, while nausea and vomiting are mainly related to chemotherapy drugs. In addition, there are other common adverse effects such as bleeding at the puncture site, white blood cell drop, transient liver function abnormalities, renal function impairment and difficulty in urination. Generally, the adverse reactions after interventional therapy will last for 5-7 days, and most patients can fully recover after symptomatic treatment. 7. Follow-up and treatment interval. It is generally recommended to review CT and/or MRI etc. at 4-6 weeks after the first hepatic artery intervention; as for the follow-up review, it can be 1-3 months apart depending on the patient's specific situation. The frequency of intervention should depend on the follow-up results. If the imaging shows dense iodine oil deposits in the liver at 4-6 weeks after the intervention, necrosis of the tumor tissue and no enlargement or new lesions, no further intervention should be done for the time being. The interval between the initial 2-3 interventions can be short. Thereafter, the treatment interval should be prolonged in the absence of tumor progression to ensure the recovery of liver function. During the treatment interval, the survival of liver tumor can be evaluated using CT and/or MRI dynamic enhancement scans to decide whether another interventional treatment is needed. If the tumor continues to progress after several interventions, switching to or combining with other treatments, such as surgery, local ablation and systemic therapy, should be considered.