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ORIGINAL ARTICLE
Year : 2015  |  Volume : 52  |  Issue : 6  |  Page : 107-111
 

Transradial arterial chemoembolization reduces complications and costs in patients with hepatocellular carcinoma


1 Department of Interventional Radiology, The First Affiliated Hospital of Henan University, Kaifeng, Henan 475001, PR, China
2 Department of Gastrointestinal Medicine, The First Affiliated Hospital of Henan University, Kaifeng, Henan 475001, PR, China

Date of Web Publication24-Dec-2015

Correspondence Address:
J He
Department of Gastrointestinal Medicine, The First Affiliated Hospital of Henan University, Kaifeng, Henan 475001
China
Z Zhao
Department of Interventional Radiology, The First Affiliated Hospital of Henan University, Kaifeng, Henan 475001
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.172505

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 » Abstract 

Purpose: To improve patient comfort and reduce complications, clinical benefit of a transradial approach for transcatheter arterial chemoembolization (TACE) was evaluated in patients with hepatocellular carcinoma (HCC). Methods: A total of 284 patients with HCC for TACE was divided into transradial approach group (n = 126) and transfemoral approach group (n = 158). These two groups of cases were retrospectively compared with regard to complications, the procedural time, X-ray exposure time, length of hospitalization, and hospital costs. Results: There were lower incidence rates of complications including abdominal distension (42.85% vs. 87.97%, P> 0.001), vomiting (53.17% vs. 77.22%, P < 0.001), lumbago (1.59% vs. 97.46%, P < 0.001), and dysuria (0% vs. 62.03%, P < 0.001) in the transradial group as compared with the transfemoral group. The time required for catheterization and total X-ray exposure time were less in the transradial group compared with the transfemoral group (Pall < 0.001). The hospital stay time and costs required for catheterization were less in the transradial group compared with the transfemoral group (P < 0.001 and P = 0.001, respectively). In addition, hepatic angiography and TACE were completed in 100% and 99.2% cases in transfemoral and transradial groups, respectively. Conclusions: Transradial approach for TACE improves quality of life in patients with HCC by offering fewer complications and lower costs compared with transfemoral approach.


Keywords: Complication, hepatocellular carcinoma, transcatheter arterial chemoembolization, transfemoral intervention, transradial intervention


How to cite this article:
Wu T, Sun R, Huang Y, Wang Z, Yin X, Zhu Z, Zhao Z, He J. Transradial arterial chemoembolization reduces complications and costs in patients with hepatocellular carcinoma. Indian J Cancer 2015;52, Suppl S2:107-11

How to cite this URL:
Wu T, Sun R, Huang Y, Wang Z, Yin X, Zhu Z, Zhao Z, He J. Transradial arterial chemoembolization reduces complications and costs in patients with hepatocellular carcinoma. Indian J Cancer [serial online] 2015 [cited 2019 Dec 7];52, Suppl S2:107-11. Available from: http://www.indianjcancer.com/text.asp?2015/52/6/107/172505

Zhijun Zhao and Jue He contribute equally to this work



 » Introduction Top


Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world. and its prognosis remains poor because of the advanced stage of cancer and associated hepatic impairment at diagnosis.[1] Transcatheter arterial chemoembolization (TACE) has been considered as one of the most important minimally invasive interventional therapies for patients with HCC at the advanced stage.[2],[3],[4] TACE blocks the blood supply of tumor, thereby inhibiting nutrient supply and starving cancer cells until these cells undergo apoptosis.[5] The transfemoral approach has become and remained the primary route of arterial access for TACE in the patients with HCC.[6],[7] However, the patient required to maintain a supine position for several hours. The procedures of femoral artery approach for TACE produce a lot of postoperational complications that affect the comfort and the quality of life in patients with HCC.[8],[9] Therefore, an alternative artery approach that could reduce post-TACE complications and improve the comfort of patients is needed.

The radial artery is small, superficial, and easily compressible. TACE by transradial approach was found to have fewer complications comparable with that of the conventional transfemoral approach.[10] With the development of catheter of radial artery and the new arterial approach technique in recent 10 years, a comparative study of transradial intervention and transfemoral intervention is necessary to determine whether transradial approach for TACE (R-TACE) is able to improve HCC patients' comfort and the quality of life in current clinical settings. In this study, the incidence rates of post-TACE complications including abdominal distension and pain, vomiting, lumbago, dysuria, nausea, and intestinal obstruction, and the time required for catheterization and total X-ray exposure time were compared in transradial and transfemoral approach groups. In addition, stay duration and costs of hospitalization which affect patients' financial burden and quality of life for TACE was also compared in transradial and transfemoral approach groups.


 » Methods Top


Patient population

Institutional review board approval was obtained at the hospital for this retrospective study, and the patients gave their full informed consent to all procedures. The subjects of the study are 284 cases diagnosed as having HCC underwent TACE between March 2012 and May 2014. Transfemoral approach for TACE (F-TACE group) was performed in 158 cases from March 2012 to May 2014, whereas R-TACE group was performed in 126 cases from March 2013 to May 2014. All R-TACE cases had a normal Allen test and a palpable ulnar artery. The cases in R-TACE and F-TACE groups were well-balanced with similar baseline clinical characteristics before TACE in two groups [Table 1]. Both groups were subjected to preoperative routine examinations including electrolyte, blood, urine, and stool tests. All patients in each group were subjected to local anesthetic. The Seldinger technique was used for puncture procedure.[11] During the procedures of TACE, digital subtraction angiography with VB23N of software version (AXIOM FA, Siemens, Munich, Germany) was used to fluoroscope the process, heparin (unfractionated heparin; Hainan Pharmaceutical Corporation, Hainan, China) was used to prevent blood clots in catheters, and verapamil (Isoptin; Hefeng Pharmaceutical Corporation, Shanghai, China) was used to prevent artery spasms. Manual compression without closure devices for hemostasis was applied for patients in both groups after the embolization. All of the procedures were performed by the same medical team.
Table 1: Baseline clinical characteristics in the patients with hepatocellular carcinoma

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Transradial approach for transcatheter arterial chemoembolization

The radial artery was punctured successfully by a 21G needle, the 5F sheath (Cordis Corporation, Baltimore, USA) was inserted into the artery. Then a 5F MPA1 (Cordis Corporation, Baltimore, USA) or JR4 (Cordis Corporation, Baltimore, USA) catheter was advanced to celiac artery, superior mesenteric artery, and phrenic artery to perform arteriography using Iohexol (Osu-300; Yangtze River Pharmaceutical Group, Taizhou, China) and to determine the conditions of the liver and tumor vessels. A 2.8F microcatheter (Renegade HI-FLO Kit; Boston Scientific Corporation, Massachusetts, USA) with a length of 135 cm was finally advanced to the related nutricia tumor vessel branches for embolization therapy [Figure 1]. An emulsion consisting of 40 mg of epirubicin (Pharmacia Upjohn; New era Pharmaceutical Corporation, Shandong, China), 10 mg of mitomycin (MMC; Haizheng Pharmaceutical Corporation, Zhejiang, China), and 5–20 ml iodinated oil injection (Lipiodol; Guerbet, Villepinte, France) were used for embolization therapy. In addition, microspheres (Embosphere; BioSphere Medical Inc., Rockland, USA) with a size of 500–700 µm or 700–900 µm which was chosen by the sizes of tumor vessels were used to enhance the embolization of tumor vessels.
Figure 1: (a-d) Transradial approach for transcatheter arterial chemoembolization in a 68-year-old man with hepatocellular carcinoma. (a) Hepatic arteriography showed tumor vessel staining by transradial approach, (b) superselective arteriography of the main nutricia tumor vessels by using microcatheter, (c) superselective arteriography of the other nutricia tumor vessels by using microcatheter, (d) arteriography after transcatheter arterial chemoembolization by transradial approach showed good tumor vessel embolization

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Transfemoral approach for transcatheter arterial chemoembolization

The femoral artery was punctured successfully with an 18G needle, the 5F sheath (Terumo, Tokyo, Japan) was inserted into the artery. Then, a 5F RH (Terumo Medical Corporation, Tokyo, Japan) or 5F Yashiro (Terumo Medical Corporation, Tokyo, Japan) catheter was advanced to celiac artery, superior mesenteric artery, and phrenic artery to perform arteriography using Iohexol (Osu-300; Yangtze River Pharmaceutical Group, Taizhou, China) and to determine the conditions of the liver and tumor vessels. A 2.7F microcatheter (Progreat; Terumo, Tokyo, Japan) with a length of 130 cm was superselective to the affected nutricia tumor vessel branches. The same embolization chemotherapy was performed as did in transradial approach.

Statistical analysis

All results were expressed as means ± standard deviation. The significance of procedural successful rate, sex, type, blood alpha-fetoprotein, type of cirrhosis, and weight loss differences between R-TACE and F-TACE groups were determined by Chi-square test. A two-tailed t-test for independent samples was used to compare two means in R-TACE and F-TACE groups. A P value of <0.05 was regarded as statistically significant.


 » Results Top


Transradial approach for transcatheter arterial chemoembolization offered fewer complications without compromising procedural success compared with transfemoral approach for transcatheter arterial chemoembolization

Hepatic angiography and TACE were completed in 100% and 99.2% cases in transfemoral and transradial groups, respectively. Because insertion of the sheath was difficult due to radial artery spasm, one failed case out of 127 cases of the transradial approach was changed to the transfemoral approach and was excluded from statistical analyses for complications, procedural and X-ray exposure time, and hospital stay time and costs. In this study, there was no significant difference in procedural successful rate (percentage of completion of hepatic angiography and TACE, 99.2% in transradial approach vs. 100% in transfemoral approach) between transradial approach and transfemoral approach groups for TACE.

All patients in both groups were followed up 1-week for complications after TACE. The most common complications including abdominal pain and distension, nausea, vomiting, intestinal obstruction, lumbago, and dysuria after TACE in all cases were monitored and recorded.[2],[3],[4] As shown in [Table 2], Chi-square test revealed that there were fewer clinical symptoms including abdominal distension, vomiting, lumbago, and dysuria in R-TACE group compared with those in F-TACE group. There were no significant differences of abdominal pain, nausea, and intestinal obstruction between R-TACE and F-TACE groups.
Table 2: Comparison of clinical symptoms

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Transradial approach for transcatheter arterial chemoembolization provided lower procedural and X-ray exposure time compared with transfemoral approach for transcatheter arterial chemoembolization

As shown in [Figure 2], t-test showed that there was lower procedural time and X-ray exposure time in R-TACE group compared with those in F-TACE group.
Figure 2: (a and b) Comparison of the procedural (operation) time (a) and total X-ray exposure (fluoroscopy) time (b) for TACE in the patients with hepatocellular carcinoma by using R-TACE and F-TACE. Results are expressed as means ± standard deviation. n = 126 in R-TACE group; n = 158 in F-TACE group. *P < 0.05 versus F-TACE. TACE: Transcatheter arterial chemoembolization, R-TACE: Transradial approach for TACE, F-TACE: Transfemoral approach for TACE

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Transradial approach for transcatheter arterial chemoembolization offered lower hospital stay time and costs compared with transfemoral approach for transcatheter arterial chemoembolization

Lower hospital stay time and hospital costs will reduce patients' financial burden, subsequently improving their quality of life. Therefore, hospital stay time (hospitalization time) and hospitalization costs in both groups were recorded and calculated. As shown in [Figure 3], t-test showed that there were lower hospital stay time and hospitalization costs in R-TACE group compared with those in F-TACE group.
Figure 3: Comparison of the hospital stay time (hospitalization time) (a) and hospitalization costs (b) for TACE in the patients with hepatocellular carcinoma by using transradial approach (R-TACE) and transfemoral approach (F-TACE). Results are expressed as means ± standard deviation. n = 126 in R-TACE group; n = 158 in F-TACE group. *P < 0.05 versus F-TACE. TACE: Transcatheter arterial chemoembolization, R-TACE: Transradial approach for TACE, F-TACE: Transfemoral approach for TACE

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 » Discussion Top


The successful rate of transradial catheterization, angiography, and intervention for TACE has been demonstrated comparable to transfemoral approach, and experienced operators spent less procedural time in transradial approach than that in F-TACE in patients with HCC in this study. There were few studies to compare transradial approach with transfemoral approach the successful rate of catheterization and procedural time for TACE in patients with HCC. A study showed there were the same successful rate and procedural time for catheterization in transradial approach and F-TACE 10 years ago.[10] The recent technique development of catheter and procedures and experienced operators may be corresponding to the shorter procedural time in transradial approach in this study.[12],[13] Efficiency of this kind of form approach of angiography has also been used in percutaneous coronary procedures.[14] The procedural times were found shorter with transradial catheterization in percutaneous coronary procedures than transfemoral procedure.[13] In addition, transradial coronary procedure had a relatively short technical learning curve.[15]

Transfemoral catheterization may require the patient to maintain a supine position for several hours, while transradial TACE is not required after the procedure.[10],[16] Certain patient populations such as elderly, obese patients, and patients with coagulopathy secondary to hepatic cirrhosis are at an increased risk of bleeding complications from femoral arterial catheterization.[17] In addition, transfemoral approach that requires bed rest can be, especially, uncomfortable in patients with chronic back problems. Fewer clinical symptoms after catheterization reflect more comfort in patients with transradial approach. A study which showed fewer postprocedural complications in transradial approach compared with conventional transfemoral guaranteed a further detail comparative analysis of clinical symptoms after these two different approaches for TACE.[10] In this study, the incidence rates of postprocedural complications including abdominal distension and pain, vomiting, lumbago, dysuria, nausea, and intestinal obstruction during the week of post-TACE procedures were compared in transradial and transfemoral groups.

This study showed there were lower incidence rates of abdominal distension, vomiting, lumbago, and dysuria in the transradial approach compared with the F-TACE in patients with HCC. The radial artery is superficial, and its hemorrhage could be easily stopped by pressure, and the patients with transradial catheterization were able to ambulate immediately following the procedure.[18] Changing transfemoral approach to R-TACE increased gastrointestinal motility and reduced the occurrence of abdominal distension and vomiting. Since the R-TACE patients did not need to lie on the bed after procedures, transradial approach reduced the incidence rate of lower back pain and decreased uncomfortable feelings in patients with chronic back problems. Urinating posture was limited because of confinement and limited lying in bed in F-TACE patients. Catheterization treatment was commonly administered to many patients with dysuria. However, this procedure not only increased patients' pain but also increased medical wastes and costs. In addition, long bed rest can induce lung infection which may cause lower extremity thrombosis and pulmonary embolism.[19] Therefore, R-TACE was a minimal invasive treatment method, causing less pain, fast recovery, and more acceptable.[10],[20],[21] There were no significant differences in the incidence rates in postprocedural abdominal pain, nausea, and intestinal obstruction between R-TACE and F-TACE groups. Abdominal pain and nausea were mainly a result of chemotherapeutic drugs, embolization of blood vessel, and tumor death. Intestinal obstruction was usually related to ectopic embolism, heavy use of pain relievers, and long limited supine in bed.

The recent technique development of catheter and experienced operators may be corresponding to the shorter procedural time and fewer complications in transradial approach. Our results have demonstrated that the application of current interventional catheter by the transradial approach can easily overcome the difficulty in superselective of a number of target blood vessels. Shorter procedural time may result in shorter total X-ray exposure (fluoroscopy) time in R-TACE group. Shorter fluoroscopy time is good for the health of patients and operators. Fewer complications and no requiring for postprocedural bed rest resulted in shorter hospital stays in R-TACE group compared with F-TACE group. These caused less staffing needed to care for patients following transradial catheterization, subsequently, reduced hospital costs in R-TACE group. All these reduced patients' financial burden and improved their quality of life. Studies of cardiovascular intervention have reported improved quality of life measures and reduced hospital costs with transradial versus transfemoral cardiac catheterization.[22] In addition, radial access reduced hospital stay by 0.4 days in coronary intervention.[23]

Cerebral embolus originating from arcus aorta might be an important complication of transradial approach although this risk is rare. Generally speaking, most of the cardiovascular interventional treatments were performed by transradial approach, without increasing the risk of stroke.[20],[24] To prevent cerebral embolus, operators should be gentle and careful with standardized operated during surgery and should have preexisting plans for emergency treatment, in the case of cerebral embolus. There was no complication case of cerebral embolus in patients with transradial approach in the current study.

There is a shortcoming of R-TACE. TACE of HCC may require repetitive processes. The radial artery tolerates repetitive puncture less well than the femoral artery. The number of times that the radial artery can be catheterized depends upon the technique of puncture and the size of the sheath. A smaller sheath, such as 4F size, might result in less trauma to the radial artery and allow repetitive procedures. Furthermore, considering the shorter surviving time in some old patients, and the patients in the late stage of HCC who will only be able to receive few repetitive procedures of TACE, the transradial approach may be more suitable for these patients. However, transradial approach is contraindicated in the patients who do not have dual blood supply from the ulnar artery as determined by the Allen test.

Together, R-TACE in patients with HCC could relieve postoperative reactions and complications considering person-based health care. This approach could improve the postoperative comfort and quality of life of patients compared with conventional femoral artery approach. Furthermore, with transradial approach, the cost of hospitalization could be reduced, and the time of hospital stay could be shortened.


 » Acknowledgments Top


This work was supported by National Natural fund Youth Project (No. 81501567) for Tao Wu.

 
 » References Top

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Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol 1953;39:368-76.  Back to cited text no. 11
    
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Kedev S, Kalpak O, Dharma S, Antov S, Kostov J, Pejkov H, et al. Complete transitioning to the radial approach for primary percutaneous coronary intervention: A real-world single-center registry of 1808 consecutive patients with acute ST-elevation myocardial infarction. J Invasive Cardiol 2014;26:475-82.  Back to cited text no. 16
    
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Kwan TW, Chaudhry M, Huang Y, Liou M, Wong S, Zhou X, et al. Approaches for dislodged stent retrieval during transradial percutaneous coronary interventions. Catheter Cardiovasc Interv 2013;81:E245-9.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]

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