1. Hepatocellular carcinoma fed by the parasitic omental branches artery: angiographic findings and interventional treatment Renjie Yang, Song Gao Peking University School of Oncology ， Beijing Cancer Hospital & Institute Department of Interventional Radiology --Hepatocellular carcinoma precise TACE--

2. Hepatocellular carcinoma precise therapy precise transarterial chemoembolization ablation ： ablation ： microwave ablation ， radio-frequency ablation ， laser ablation ， microwave ablation ， radio-frequency ablation ， laser ablation ， High Intensity Focused Ultrasound (HIFU) cryo-ablation cryo-ablation ethanol ablation ， ablation ethanol ablation ， acetic acid ablation radioactive particle ： Individual combined therapy principle ： ， intergration conformity ， evidence based medicine, first-visit responsibility ， intergration conformity ， evidence based medicine, Individual treatment---Tailor

3. Background— Precise TACE TACE ---the most mature and effective treatment methods for non-surgical treatment HCC. The quality of TACE effect were not only associated with the tumor vessels embolization but also associated with full showing extrahepatic parasitic artery and precise TACE. Omental artery (OA) --- one of rare extrahepatic parasitic artery supplying HCC.

4. Objective To analyse angiography manifestations and characteristics of HCC fed by omental artery (OA). To analyse angiography manifestations and characteristics of HCC fed by omental artery (OA). To evaluate the feasibiliy 、 therapeutic effect and safety of TACE through the OAs. To evaluate the feasibiliy 、 therapeutic effect and safety of TACE through the OAs.

5. Methods 1,221 patients with HCC who had done interventional therapy between Jan. 1998 and Feb. 2008. 32 patients were found feeding not only hepatic A. but also by parasitic OAs were enrolled in the study. 19 patients were performed TACE with microcatheter through OAs.

6. Methods The OAs incidence rate, successful rate of superselective catheterization were reported. Reaction after TACE via the OA was evaluated. The cumulative survival rates （ 6 、 12 、 18 and 24 months ） of 19 patients who performed successfully chemo-embolization through OAs and the other 13 failed cases were calculated respectively.

8. RESULT-1 1,221 cases performed 3,639 interventional procedures. 32 cases were found parasitic OA, frequency: 2.62% （ 32/1221 ）. 6 patients were found OA supplying at the first TACE 32 cases were found parasitic OA, frequency: 2.62% （ 32/1221 ）. 6 patients were found OA supplying at the first TACE procedure. 76 interventional procedures were found parasitic OA, giving a frequency of 2.09% （ 76/3639 ），

9. RESULT-2 97 parasitic OA branch were found in 32 patients. 6 patients were found OA supplying at the first TACE 97 parasitic OA branch were found in 32 patients. 6 patients were found OA supplying at the first TACE procedure. 62 OA branches with microcatheter were performed superselective TACE, successful rate was 63.9%(62/97).

10. RESULT-3 16 patients had 2 or more repeated OA TACE 12 cases OAs occlusion, 12 cases OAs occlusion, 4 cases of OA reperfusion, 4 cases of OA reperfusion, 3 cases were found new parasitic vessel from 3 cases were found new parasitic vessel from the nascent OA. the nascent OA. OA parasitic blood supply of HCC lesions mainly was in the right and left medium lobe. OA parasitic blood supply of HCC lesions mainly was in the right and left medium lobe. 2 postoperative recurrence cases were found parasitic vessel from OA.

11. RESULT-4 Angiography characteristics ： (1) hypertrophy of the feeding OAs were noted in 28 patients (n=28) ； (2) OAs’ edges are (n=11) HCC compressed gastroduodenal artery and it’s branches displaced were noted ； (2) OAs’ edges are untidily and rigidity (n=11), huge HCC compressed gastroduodenal artery and it’s branches displaced were noted ； (3) defective tumor staining or defective lipiodol deposit in 7 patients (n=7).

15. RESULT-5 Reaction after TACE ( TACE through the parasitic OAs were performed in 19 patients ) ： Fever 18 cases ； 15 cases ； Stomachache 15 cases ； 、 16 cases ； nausea 、 vomit 16 cases ； Except one acute pancreatitis; there was no serious complication that related to the OA chemoembolization, such as omental or bowel ischemia 、 perforation.

16. RESULT-5 Super-catheterization through the parasitic OA were failed in 13 patients ， they were performed TAI. Super-catheterization through the parasitic OA were failed in 13 patients ， they were performed TAI. Fever 10 cases ； 4 cases ； Stomachache 4 cases ； ； nausea 、 vomit 12 cases ；

17. RESULT-6 The cumulative survival rates of the 19 TACE cases were 78.9% at 6 months 、 47.4% at 12 months 、 31.6% at 18 months 、 21.1% at 24 months ； 13 TAI cases were 61.5% at 6 months and 30.8% at 12 months 、 15.4% at 18 months 、 7.7% at 24 months ； among them ， 2 patients died of hemorrhage of ruptured HCC.

18. Discussion-1 1 、 Mechanism of HCC fed by OA 1 、 Mechanism of HCC fed by OA （ 1 ） Bulky HCC ， grow invasively and break through the liver capsule ， direct invasion of the great omentum and adjacent access to OA parasitic blood supply. （ 1 ） Bulky HCC ， grow invasively and break through the liver capsule ， direct invasion of the great omentum and adjacent access to OA parasitic blood supply. （ 2 ） Hepatic artery was stenosis or occlusion ， hypoxia occurred in the cancer nest ， then VEGF etal regulated start ， leading to tumor recurrence, metastasis ， and promoting such as OA the formation of HCC extrahepatic parasitic vascular. （ 2 ） Hepatic artery was stenosis or occlusion ， hypoxia occurred in the cancer nest ， then VEGF etal regulated start ， leading to tumor recurrence, metastasis ， and promoting such as OA the formation of HCC extrahepatic parasitic vascular. （ 3 ） For using of omental tissue suture on the liver resection margin to stop bleeding 、 Omentum walk to the surgical field after operation, when HCC margins or local recurrence 、 omental adhesion with tumor, OA parasitic vessel may appeard. （ 3 ） For using of omental tissue suture on the liver resection margin to stop bleeding 、 Omentum walk to the surgical field after operation, when HCC margins or local recurrence 、 omental adhesion with tumor, OA parasitic vessel may appeard.

19. Discussion -2 2 、 Angiography characteristics of HCC fed by OA. 2 、 Angiography characteristics of HCC fed by OA. Position ： Generally ， OA originated from the gastroduodenal artery or pancreaticoduodenal artery arch ， distributed in the greater omentum ， As long as there is retinal tissue coverage ， Any segment of the HCC liver may occur OA parasitic blood supply. Position ： Generally ， OA originated from the gastroduodenal artery or pancreaticoduodenal artery arch ， distributed in the greater omentum ， As long as there is retinal tissue coverage ， Any segment of the HCC liver may occur OA parasitic blood supply. In our study ， we found that any segment of the liver may occur OA parasitic blood supply ， except S2 ； But the most common occurred in the right lobe and left lobe. In our study ， we found that any segment of the liver may occur OA parasitic blood supply ， except S2 ； But the most common occurred in the right lobe and left lobe.

20. Abdominal enhanced CT ： the edge of the tumor arterial thickening, strongly indicate the presence of parasitic OA blood vessel.

21. Discussion -3 3 、 Superselective Intervention 3 、 Superselective Intervention OA lumen small 、 tortuous ， their average diameter was only 2- 3mm ， normal angiography usually was not obvious. When parasitic OA blood supply, the diameter may be significantly enlarged. Using the microcatheter will help improving the success of OA superselective catheterization. In this group of cases OA superselective catheterization success rate was 63.9%. In this group of cases OA superselective catheterization success rate was 63.9%. Reasons of superselective failure ： OA was too fine ； sharp angular between branch and the trunk ； multi-cluster support OA was invaded so plexiform. Reasons of superselective failure ： OA was too fine ； sharp angular between branch and the trunk ； multi-cluster support OA was invaded so plexiform.

22. Use of microcatheter —TACE

24. Use of micro-catheter—first TACE

27. Use of micro-catheter— 2nd TACE Use of micro-catheter— 2nd TACE -----OA branches involved in blood supply----- -----OA branches involved in blood supply-----

28. Use of microcatheter— OAs TACE

29. Use of microcatheter —KUB after OAs TACE

30. Discussion-5 OA Too Fine Discussion-5 OA Too Fine OA was too fine, superselective catheterization was failure (black arrow), there gastroduodenal drainage vein in the immediate cessation of embolization (white arrow)

31. Discussion-5 Prevention of complications Even a small amount of normal OA was embolizated ， Serious complications such as intestinal ischemia or infarction, ulcers, perforation, usually do not appear 。 in this study ， no serious complications of gastrointestina don’t appeared. 1 patient was supported acute pancreatitis by abdominal pain, abdominal CT diagnosis was clear ， the reason considering the small amount of embolic material reflux ； OA TACE would increase the local branch which was already stiff, the damaged intestinal wall would be ischemia, edema ， Risk of gastrointestinal ulcers or perforation, intestinal necrosis Increased ， after TACE ， We should be inhibiting gastric acid secretion, antiemetic, gastric mucosal protective agent treatment 3-5 days.

32. Discussion-6 Prevention of HCC rupture About 10% HCC patients died of cancer nodules bleeding,arterial embolization was effective way on the emergency treatment of HCC rupture. Follow-up: of the 13 cases that super-catheteration through the parasitic OAs were failed, 2 patients died of HCC bleeding. OA was often involved liver capsule edge, which is part of HCC rupture of location, so embolization of the OA for the prevention of HCC rupture may be a potential preventive effect.

33. Discussion-7 Survival follow-up 19 cases who were performed precise OA branch TACE, the cumulative survival rate was higher than non TACE group. Embolization of precise OA branch would improve the effect of HCC intervention and had potential clinical value. However, appearing of extrahepatic parasitic blood supply to HCC was only prompted one of the factors of poor prognosis, so we don’t conclude that the OA branch TACE treatment cound significantly prolong survival in patients with HCC. Combination of local chemical and physical ablation, Solafeini, thalidomide and other molecular targeted therapy may increase efficacy.

34. Conclusion OA is one of rare extrahepatic parasitic arterys OA is one of rare extrahepatic parasitic arterys supplying HCC. supplying HCC. Through OA TACE with microcatheter is relatively safe and feasible ， to prevent hemorrhage of ruptured HCC and to raise interventional therapy effect have potential clinical value. is our direction forever. Precise TACE is our direction forever.

35. Peking University Cancer Hospital ， Department of Interventional Radiology Interventional Radiology

36. 第二届亚太肿瘤介入大会（ APCIO 2011 ） 第十二届全国肿瘤介入大会 2011 年 10 月 27 日 -30 日, 杭州第一大世界 2 nd. Asia-Pacific Conference on Interventional Oncology, APCIO 2011 Oct. 27-30, 2011, Hangzhou, China