Introduction

Hepatocellular carcinoma (HCC) is the most common primary liver cancer worldwide, and its incidence is rising. Unfortunately, conventional therapies such as systemic chemotherapy or external radiation have proven ineffective as treatment options. Moreover, few patients presenting with malignant hepatic tumors are candidates for surgical resection.

The development of catheter and guidewire technology has facilitated embolization, allowing for the superselective placement of catheters for the safe and effective delivery of therapeutic and radioactive agents to hepatic tumors. With experience and a trained hand, microcatheters and guidewires can be safely placed, even in the presence of aberrant vessels or a collateral blood supply.

This case study highlights the transarterial hepatic embolization technique in a complex case of unresectable HCC.

Procedure Description

A 65-year-old man presented with unresectable HCC. The celiac artery was accessed using a reverse-curve catheter. Upon evaluation, extremely tortuous vasculature was observed, much more challenging than what is typically seen in liver embolization cases. A 180-cm Fathom® 16 Steerable Guidewire was placed within a Renegade® HI-FLO™ Microcatheter, shaped, and inserted into the celiac artery and right hepatic artery. The guidewire's combined shapeability and torquablity facilitated navigation through very tortuous anatomy, including one hepatic trifurcation and six tight vascular 360º loops. The Renegade® HI-FLO™ Microcatheter provided excellent trackability and radiopacity, allowing accurate delivery of the embolic agent to the tumor site, as expected.

The total procedure time was 30 minutes. The fact that the Fathom® Guidewire maintained its body and facilitated placement and catheter tracking without vessel spasm may have contributed to the abbreviated procedure time.

Discussion

In selecting a guidewire for complex cases, a balance of attributes may be considered. The Fathom® Guidewire offers the nice balance of a soft, shapeable tip to cater to various patient anatomies, combined with excellent torquability. In this case, the trackability, pushability, and kink resistance of the guidewire allowed for the navigation of the microcatheter through extremely tortuous anatomy.

Riad Salem, MD, MBA, is the Director of Interventional Oncology at Northwestern Memorial Hospital in Chicago, Illinois.