Transradial approach facilitates same-day discharge for transarterial chemoembolization to treat hepatocellular carcinoma

1. TRANSRADIAL APPROACH FACILITATES SAME-DAY
DISCHARGE FOR TRANSARTERIAL
CHEMOEMBOLIZATION TO TREAT HEPATOCELLULAR
CARCINOMA
Ram Posham MPA, RS Patel MD, RA Lookstein MD FSIR, FS Nowakowski MD FSIR,
E Kim MD, AM Fischman MD
Division of Interventional Radiology
Icahn School of Medicine at Mount Sinai
New York, NY

2. Disclosures
• Ram Posham: None
• Aaron Fischman: Consultant, Surefire Medical, Inc; Consultant, Terumo
Corporation; Speakers Bureau, Koninklijke Philips Electronics NV
• Rahul Patel: Consultant, Sirtex Medical Ltd Research; Consultant, Arstasis,
Inc
• Edward Kim: Consultant, Koninklijke Philips Electronics NV; Advisory Board,
Onyx Pharmaceuticals, Inc; Advisory Board, Nordion, Inc
• Francis Nowakowski: Nothing to disclose
• Robert Lookstein: Consultant, Bayer AG; Consultant, Johnson & Johnson;
Consultant, Boston Scientific Corporation

3. Background – Hepatocellular Carcinoma (HCC)
 6th leading cause of cancer
worldwide
 Ranked #3 most common cancer-related
deaths
 Etiologies:
 Hep. B/C (80%)
 Cirrhosis
 Aflatoxins, Heridatory Hemachromatosis
 Curative Resection (10% – 30%)
 Nonresectable treatment
 Transplant
 Transarterial Chemoembolization
 Radiofrequency Abalation

4. Background – Transarterial Chemobolization
 Transarterial Chemoembolization (TACE) Goal:
 Block branch arteries feeding tumors
 Reduce blood supply to lesion, induce ischemia
 Response measured based on tissue necrosis %
 Beads, microspheres, gelatin sponges, coils, etc.
 Enhance tumor response via selective chemotherapy
 Types: Bland, DEB-Tace, C-Tace
 “Survival probabilities at 1 year and 2 years … 82% and 63% for
chemoembolisation, and 63% and 27% for control” 1
1. Llovet JM, Real MI, Montaña X, et al. Arterial embolisation or chemoembolisation versus
symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised
controlled trial. Lancet. 2002;359(9319):1734-9.

5. Background - Milestones
 1978 – first embolization of hepatic neoplasm
 Shermeta DW, Golladay ES, White RI. Preoperative occlusion of the hepatic artery with isobutyl 2-cyanoacrylate for
resection of the "unresectable" hepatic tumor. Surgery. 1978;83(3):319-22.
 1988 – first randomized trial of chemoembolization to
treat HCC
 Lin DY, Liaw YF, Lee TY, Lai CM. Hepatic arterial embolization in patients with unresectable hepatocellular
carcinoma--a randomized controlled trial. Gastroenterology. 1988;94(2):453-6.
 2002 – first publication on TACE outcomes to treat HCC
via radial artery
 Shiozawa S, Tsuchiya A, Endo S, et al. Transradial approach for transcatheter arterial chemoembolization in
patients with hepatocellular carcinoma: comparison with conventional transfemoral approach. J Clin
Gastroenterol. 2003;37(5):412-7.
 2012 – first trial on TACE to treat HCC w/ same-day
discharge (Transfemoral Approach)
 Prajapati HJ, Rafi S, El-rayes BF, Kauh JS, Kooby DA, Kim HS. Safety and feasibility of same-day discharge of
patients with unresectable hepatocellular carcinoma treated with doxorubicin drug-eluting bead transcatheter
chemoembolization. J Vasc Interv Radiol. 2012;23(10):1286-93.e1.

6. Background – Current Status of TACE for HCC
 # of Tace cases performed a year
 Most centers perform TACE with at least 1 day admission
 Concerns: access site complications, post-embolization syndrome,
or fulminant liver failure
 2014 - Same day discharge feasible in 89.5% of TACE
cases to treat HCC with no emergency readmission rates
at 30 days (n = 266)1
 Transfemoral Access
 Average post-procedural recovery time prior to discharge: 6
Hours
 Hospital reimbursements for TACE largely lump-sum
1. Nasser F, Cavalcante RN, Galastri FL, et al. Safety and feasibility of same-day discharge of patients
with hepatocellular carcinoma treated with transarterial chemoembolization with drug-eluting beads
in a liver transplantation program. J Vasc Interv Radiol. 2014;25(7):1012-7.

7. Purpose
– Does Transradial Access help facilitate same-day
discharge for patients undergoing TACE to treat
HCC? ????

8. Materials and Methods
 Retrospective analysis of 21 continuous patients selected
for same-day TACE from 2/2014 to 7/2014
 12/21 treated via TRA
 Inclusion criteria
 ECOG Score 0 or 1
 Child-Pugh Score A or B
 Endpoints
 Technical success
 30 day minor and major AEs
 Fluoroscopy time

9. Materials and Methods
 Barbeau test
Barbeau et al. Am Heart J 2004;147:489–93

10. Materials and Methods
 Antispasmodic cocktail administered
 3000 u heparin
 200 mcg nitroglycerine
 2.5 mg verapamil

11. Materials and Methods
 Radial Artery Homeostasis via TR Band1
 non-occlusive pressure at the arteriotomy
 Removal: 60-90 minutes
1. TR Band (Terumo Interventional Systems, Somerset, NJ)

12. Results – Technical Endpoints
 21 consecutive patients – 2/2014 to 7/2014
 Technical Success: 100%
 Same Day Discharge: 100%
 Average post-procedural time to discharge via TRA
Access: 2h 15min
Access
Site
Patients
(#)
Average
Age
Avereage
BMI
Average
Fluoro
Time (min)
Average
Recovery
Time (H:M)
Radial Artery 12 62 24.9 25.1 2:15
Femoral Artery 9 63 25.9 17.1 2:56

13. Results – Safety Endpoints
 No major adverse events at 30 days
 Radial approach
 Grade 1 hematoma: 1 patient
 Asymptomatic
 Immediate Ambulation

14. Study Limitations
 Fluoroscopy Time
 25.1 minutes for TACE via Transradial Access versus
17.1 minutes via Transfemoral Access
 Learning curve
 Small Sample Size
 Theoretical risk of cerebral infarction secondary to arch
manipulation – felt to be exceedingly low based on
cardiology studies

15. TRA use in Same-day Discharge for HCC TACE
 Patient comfort
 Hemostasis in 1-2 hours
 Immediate post-procedure ambulation
 At least 25% faster post-procedure discharge
 Patient preference
 Lower overall access site complication rates
 Faster Discharge
 Reduced FTEs required to manage patient recovery
 Potential source of cost savings
1. Posham R, Fischman AM, et al. Transradial approach for peripheral and visceral interventions: a
single center review of safety and feasibility in the first 1000 cases. (Abstract submitted to SIR 2015)

16. Conclusion
TRA appears to be feasible and safe in HCC
patients undergoing same-day TACE, and
facilitates same-day discharge by minimizing
post-procedural discharge times and allowing
nearly immediate ambulation.