Balloon-Occluded Radiofrequency Ablation as Bridge to TACE in theTreatment of Advanced HCC with Arterioportal Shunt

Background: Transarterial chemoembolization is the most widely used palliative treat-ment for unresectable hepatocellular carcinoma; however, arterioportal shunt represents a contraindi-cation to this treatment. Objective: The study aims to assess the feasibility of balloon-occluded radiofrequency ablation in the transitory resolution of an extensive arterioportal shunt in patients with advanced hepatocellular carci-noma as a bridge to safe and effective transarterial chemoembolization. Methods: 12 consecutive patients advanced multinodular unilobar unresectable hepatocellular carci-noma with a target lesion larger than 5 cm (mean diameter 7.7 ± 1.4 cm), not suitable to transarterial chemoembolization due to extensive arterioportal shunt, were recruited. Balloon-occluded radiofre-quency ablation of the hepatic area surrounding the shunt during occlusion of the artery supplying the shunt was performed, followed by lobar conventional chemoembolization. Intra/periprocedural complications were evaluated. Technical success was defined by the result of radiofrequency abla-tion in terms of immediate disappearance, reduction, or persistence of the shunt. Local efficacy of chemoembolization was evaluated at 1-month computed tomography according to m-RECIST crite-ria. Results: Technical success was achieved in all patients. No major complications were observed. 1-month follow-up showed a mean necrotic diameter of 6.3 cm (range: 3.8-8.7 cm), with an acceptable procedural result and persistence of the shunt. An overall response rate was obtained in all patients, with 25% complete response and 75% partial response. Conclusion: Balloon-occluded radiofrequency ablation of an arterioportal shunt in patients with ad-vanced hepatocellular carcinoma can temporarily reduce shunting, allowing to perform safe and ther-apeutically useful chemoembolization, with satisfactory control of tumor growth.