Chemoembolization in Patients at High Risk: Results and Complications James M. Kiely, MD, William S. Rilling, MD, John G. Touzios, MD, Robert A. Hieb, MD, Jose Franco, MD, Kia Saeian, MD, Edward J. Quebbeman, MD, PhD, and Henry A. Pitt, MD PURPOSE: Transarterial chemoembolization (TACE) has become a standard treatment option for unresectable hep- atocellular carcinoma (HCC) and is often used to palliate hepatic metastases. Many patients who are candidates for TACE present with poor hepatic reserve, advanced tumor stage with major portal vein (PV) invasion or thrombosis, and/or biliary dilation. These factors have been associated with a poor prognosis and increased complications after chemoembolization. Accordingly, these patients are classified as being at high risk and may not be considered for therapy. The aim of this study is to evaluate the results of TACE in these patients. MATERIALS AND METHODS: Over a period of 5 years, 141 patients underwent 355 TACE procedures. Thirty-six patients (26%) were in the high-risk group as a result of major PV thrombosis, increased serum bilirubin level (>2 mg/dL), and/or intrahepatic biliary dilation. HCC was the underlying tumor in 60% of patients. Thirty-seven percent of patients had Child-Pugh class B/C disease. Patients in the high-risk group received more selective embolization with fewer particles and fewer procedures (2.0 vs 2.7; P < .04). RESULTS: Patients in the high-risk group were more likely to have HCC (83% vs 51%; P < .01) and were also more likely to have advanced disease according to Child-Pugh classification versus patients in the low-risk group (49% vs 20%; P < .01). The overall complication rate was 4.3%, with no significant difference in complication rate between groups (3.2% vs 8.2%; P  .12). The overall 30-day mortality rate was 2.3%, and no significant difference in 30-day mortality rate was observed between the high- and low-risk groups (5.5% vs 1.4%; P  .11). A trend toward increased survival in the low-risk group did not reach statistical significance. CONCLUSIONS: These data suggest that patients with advanced disease and decreased hepatic reserve who are treated with TACE exhibit no significant increase in morbidity or mortality and no significant decrease in survival. With variations in technique, TACE can be performed safely in patients with the relative risk factors that may classify them in high-risk groups. J Vasc Interv Radiol 2006; 17:47–53 Abbreviations: HCC = hepatocellular carcinoma, PV = portal vein, TACE = transarterial chemoembolization TRANSARTERIAL chemoemboliza- tion (TACE) is a regional therapeutic modality that has become an accepted treatment for unresectable hepatocel- lular carcinoma (HCC). A recent sys- tematic metaanalysis of randomized trials by Llovet et al (1) confirmed a distinct survival advantage for TACE compared with symptomatic treat- ment alone. TACE is also used as pal- liative therapy for patients with unre- sectable liver metastases from a variety of causes (2–5). In addition, TACE can be used as neoadjuvant therapy to improve resectability in pa- tients under consideration for hepatic resection and has been used to stabi- lize disease in patients with HCC awaiting orthotopic liver transplanta- tion (6–8). Unfortunately, many patients who are under consideration for TACE present with advanced disease result- ing in major portal vein (PV) invasion or thrombosis, poor hepatic reserve with increased serum bilirubin levels, and the presence of significant intra- hepatic biliary dilation, which are all considered risk factors for adverse outcomes and/or poor survival after TACE. Major PV thrombosis and/or invasion by tumor have long been considered relative contraindications for TACE because of the potential risk of hepatic insufficiency resulting from ischemia after treatment. It is estab- lished that chemoembolization can be performed in this patient population with changes in technique. Studies From the Departments of Surgery (J.M.K., J.G.T., E.J.Q., H.A.P.), Vascular and Interventional Radiol- ogy (W.S.R., R.A.H.), and Medicine (J.F., K.S.), Med- ical College of Wisconsin, 9200 West Wisconsin Av- enue, Milwaukee, Wisconsin 53226. Received May 13, 2005; accepted October 3. Address correspon- dence to W.S.R.; E-mail: wrilling@mcw.edu None of the authors have identified a conflict of interest. © SIR, 2006 DOI: 10.1097/01.RVI.0000195074.43474.2F 47