Spongiform hemangioma is the most common benign tumor of the liver, and hepatic artery embolization, especially sclerosing embolization, has so far become an important treatment for hepatic cavernous hemangioma due to its reliable efficacy and few treatment complications. Anhydrous ethanol has been widely used in clinical practice as an effective permanent embolic agent. The author applied anhydrous ethanol and super-liquefied iodized oil in the ratio of 2:1 to form an emulsion, and achieved satisfactory results in 25 cases of hepatic hemangioma treated with transcatheter intravascular embolization. 1. Materials and methods (1) General data: From August 2001 to December 2009, a total of 25 cases of hepatic cavernous hemangioma were treated by transcatheter arterial embolization in our hospital, of which 10 cases were male and 15 cases were female, aged 28-66 years (average 46.4 years). The main symptoms were vague pain in the right upper abdomen in 5 cases, acute upper abdominal pain and shock in 1 case, right upper abdominal mass in 2 cases, abdominal distension in 8 cases, and progressive enlargement of the lesion in 9 cases. Laboratory tests showed mild anemia in 2 cases and mild platelet reduction in 3 cases. The time from the appearance of symptoms to treatment ranged from 1 day to 12 years. All cases were clearly diagnosed by ultrasound, dynamic CT scan and MRI, and one case suggested spontaneous tumor rupture and bleeding. The maximum tumor diameter ranged from 6.5 cm to 15.3 cm (8.15±2.03 cm), with 12 cases of single mass type and 13 cases of multiple nodules type. The largest lesions were located in 15 in the right lobe of the liver and 10 in the left lobe of the liver. (2) Methods and steps: a. Preoperative routine blood, liver function, kidney function, coagulation function and electrocardiogram were performed routinely. The size, distribution and scope of the tumor were clarified by routine abdominal ultrasound, CT or MRI enhancement examination. b. Before embolization, abdominal cavity artery, superior mesenteric artery and hepatic artery imaging were routinely performed to clarify the number of tumors, blood supply and arteriovenous fistula. c. Anhydrous ethanol (99.9% medical analysis alcohol) and super-liquefied iodized oil were prepared into anhydrous ethanol-iodized oil emulsion with a volume ratio of 2:1, which was initially measured according to the hand-push imaging. The anhydrous ethanol-iodide oil emulsion was injected slowly via 3F microcatheter under x-ray surveillance, with the catheter super-selected as close to the tumor as possible. The embolic agent dosage was 8-25 ml (average l2.5m1). The injection rate was 0.5-1.0 ml/s. The contrast was reviewed until the lesion staining disappeared. If a hepatic arteriovenous fistula is present in the lesion, the microcatheter is placed at the fistula and embolized with anhydrous ethanol or 500-700 μm diameter PVA pellets + anhydrous ethanol. Two to three ml of 1% lidocaine was pushed intra-arterially to relieve pain before ethanol injection. All cases were treated with postoperative liver protection, anti-inflammatory and symptomatic therapy, and liver function was rechecked at 1 week and 2 weeks after treatment, and ultrasound and CT/MRI were performed at 1, 3, 6 and 12 months. 2. Results (1) Angiographic manifestations and embolization According to the typing of Zeng Qingle et al, among 25 patients, 20 were blood-rich, 2 were blood-deprived, and 3 were arteriovenous fistulas. A total of 27 embolization treatments were performed, including 3 patients treated twice, and all cases were successfully embolized. The amount of embolic agent used ranged from 8 to 25 ml (mean l2.5 m1). Post-embolization angiography showed iodine oil aggregation in the lesion area and disappearance of blood sinus staining in the lesion area. (2) Efficacy and adverse effects Six months and 12 months after embolization, ultrasound and CT scan showed significant tumor shrinkage (5.3 ± 1.6 cm, t=5.513, P<0.01)) and (2.8 ± 1.2 cm, t=25.412, P<0.01)), respectively, and patients' clinical symptoms including abdominal pain, abdominal distension, abdominal mass, anemia and decreased platelets were relieved. Postoperatively, except for mild liver distension, fever, nausea and vomiting, most of them resolved on their own in 3-7 days or with symptomatic treatment; postoperative transaminases recovered after 2 weeks of mild elevation, and no liver abscess, jaundice, bile tumor, gallbladder perforation, liver failure and other serious complications occurred. 3.Discussion Spongiform hemangioma is the most common benign tumor of the liver, with an autopsy incidence of 0.4% to 7.0%. With the advancement of diagnostic imaging technology, the number of cases of hepatic cavernous hemangioma is increasing day by day, and it can occur at any age, but mostly in 30-50 years old, and more women than men. Hepatic cavernous hemangioma can be generally divided into three levels: (1) small cavernous hemangioma with a maximum diameter of <4 cm; (2) large cavernous hemangioma with a diameter of 5-10 cm; (3) those with a maximum diameter of >10 cm are called giant cavernous hemangioma. In larger cases, symptoms include abdominal mass, epigastric distension, vague pain in the liver area, occasional nausea, vomiting, obstructive jaundice, and gastric pyloric obstruction. Giant hepatic cavernous hemangiomas can sometimes present with varying degrees of anemia, thrombocytopenia, and hypofibrinogenemia. Mild anemia occurred in two patients and mild thrombocytopenia occurred in three patients in this group. Hepatic cavernous hemangioma usually does not rupture spontaneously, but it is more common for hemorrhage to occur within a giant hepatic cavernous hemangioma or to have a history of intratumoral hemorrhage. One case of hemangioma in this group developed shock due to internal hemorrhage. The majority of hepatic cavernous hemangiomas are asymptomatic and are found only on normal examination without treatment. The currently accepted indications include symptomatic hemangiomas, hemangiomas larger than 5 cm in diameter with enlarged lesions or at risk of bleeding. Because of the large size of the hepatic giant cavernous hemangioma, the difficulty of surgical resection, and the mortality and uncontrollable bleeding associated with surgery, most patients are currently reluctant to undergo surgery, while transarterial embolization is less invasive, less reactive, and highly effective. The mechanism of treatment is that the hemangioma is mainly supplied by the hepatic artery, and embolization of the diseased supplying artery causes the lesion to shrink and the symptoms to be relieved. As a radical treatment for cavernous hemangioma, embolic agents are generally required to have a permanent embolic effect, both to completely fill the tumor vascular bed and to effectively prevent the establishment of collateral blood supply. Anhydrous ethanol is the most effective embolic agent. Theoretically, anhydrous ethanol has the strongest embolic effect, but because of its invisibility under fluoroscopy, it is often mixed with a certain amount of contrast agent such as iodized oil in clinical application so that it can be closely monitored during injection, and to prevent misembolization caused by reflux during injection, in addition, balloon catheter injection or microcatheter super-selective cannulation can be used to protect normal tissues as much as possible. The author has embolized 16 renal vascular smooth machine lipomas, 8 of which were embolized with anhydrous ethanol iodine oil (anhydrous ethanol: iodine oil = 2 to 3:1) and 8 with pinyamycin super-liquefied iodine oil emulsion, with a follow-up follow-up of 4 months to 5 years, averaging 36.5 months, resulting in 5 patients requiring a second intervention, including 3 cases of pinyamycin super-liquefied iodine oil emulsion embolization, including 2 cases of rebleeding , embolization followed by surgical resection. Based on this, in this study, we used anhydrous ethanol-iodine oil emulsion embolization (anhydrous ethanol: iodine oil = 2:1), which resulted in a maximum tumor diameter of 6.5 cm to 15.3 cm (8.15 ± 2.03 cm) in 25 patients, with significant tumor shrinkage at 6 and 12 months after embolization (5.3 ± 1.6 cm and 2.8 ± 1.2 cm, respectively), indicating a reliable treatment effect. The mechanism of embolization caused by anhydrous ethanol in target organs: (1) endothelial damage caused by contact between ethanol and vascular endothelial cells; (2) damage to the blood’s organic fraction and protein denaturation and precipitation; (3) alteration of the local blood rheological properties, i.e., spasmodic contraction and subsequent expansion of the vascular wall after stimulation by ethanol, expansion of blood from axial flow to side flow, and attachment of leukocytes and degraded proteins to the ethanol-damaged endothelium. (4) ethanol can penetrate directly or enter the tissue through the endothelial fissure to denature the tissue cells, resulting in the loss of enzyme system and protein biological activity; (5) micro thrombus formation in the blood vessel. The combination of iodinated oil and anhydrous ethanol has a mutually reinforcing effect, as the former prolongs the action of the latter, while the latter delays the clearance of the former in the foci, and the combination of the two is beneficial for x-ray follow-up, monitoring of the cinnamon process, and follow-up observation. As an embolic agent for hepatic cavernous hemangioma, the efficacy of anhydrous ethanol and iodinated oil emulsion depends on the embolization speed and embolization dosage. If the embolization speed is too fast, the proximal vessels will be embolized first and the distal vessels and tumor body will be affected; if the speed is too slow, the ethanol will be diluted by blood and incomplete embolization will be formed easily. The dosage of embolic agent should be determined by factors such as too small tumor and rich blood supply. The author experiences that the embolization speed should be determined according to the depth of the catheter, the size of the target vessel in the anterior segment of the catheter and the hand-push contrast, and a speed of 0.2~0.5 ml/s is appropriate. If the diameter of the tumor is too large >20 cm, the tumor can be embolized in several times to achieve complete embolization of the tumor as much as possible: 5-25 ml of single embolization agent is appropriate, and the use of microcatheters is recommended if possible, because the blood supply arteries of cavernous hemangioma are often more twisted and thickened than those of primary hepatocellular carcinoma, especially the lack of blood, and it is often difficult to avoid the normal vascular branches, especially the gallbladder artery and the right gastric artery. gallbladder artery, right gastric artery, etc., and sometimes may cause spasm and entrapment of the responsible artery, which can more effectively embolize the tumor, protect normal tissues, reduce postoperative adverse effects, and shorten the hospital stay. All the cases in this group were treated with microcatheters, and the postoperative adverse effects were mild. Except for 3 cases with huge lesions, the maximum diameter of which exceeded 15 cm, and the presence of hepatic artery portal fistula in the lesion area for 2 embolization treatments, all the cases were successfully treated in 1 time. Therefore, the author believes that embolization of hepatic hemangioma with a volume ratio of 2:1 anhydrous ethanol to iodized oil emulsion is an effective, convenient and safe method. A, 45-year-old female with right upper abdominal distension and vague pain for 1 year. A, Enhanced CT scan showed a giant hemangioma in the right lobe of the liver, 8.6×6.4×14.2 cm3. B, Abdominal arteriogram showed a large “popcorn-like” tumor staining area in the right lobe of the liver and a smaller lesion in the left outer lobe. C Superselective transcatheter hepatic artery embolization with anhydrous ethanol-iodine oil emulsion (anhydrous ethanol: iodine oil = 1:1, total 25 ml) showed deposition of iodine oil emulsion all over the lesion area.