Cystic artery embolism after transarterial chemoembolization for hepatocellular carcinoma: A case report and review of the literature

Table 1 Alterations in full blood count and liver function tests in our patient following transarterial chemoembolization

Blood test (reference value)	1 week after TACE	2 weeks after TACE	Before exploratory laparotomy	2 days after surgery	1 week after surgery
Hb (115-150 g/L)	111	115	86	73	112
PLT (125-350 × 109/L)	75	113	190	152	217
WBC (3.5-9.5 × 109/L)	8.53	13.12	15.34	15.11	10.69
N (0.4-0.75)	0.809	0.925	0.83	0.874	0.77
ALP (50-135 U/L)	122	160	157	117	443
TBil (0-23 umol/L)	11.29	19.93	31.17	16	35.9
ALB (40-55 g/L)	22.8	23.6	36.9	30.2	42.4
ALT (7-40 U/L)	63	118	37	30	19
AST (13-35 U/L)	44	77	29	30	27
GGT (7-45 U/L)	76	89	84	48	250

TBiL: Total bilirubin; TACE: Transarterial chemoembolization; Hb: Hemoglobin; PLT: Platelet; WBC: White blood cell; ALP: Alkaline phosphatase; ALB: Albumin; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; GGT: Gamma-glutamyl transferase.

Table 2 Summary of significant literature findings

Ref.	Findings	Contributions
Marcacuzco Quinto et al[6]	Out of the 196 patients with liver tumors who had undergone 322 TACE procedures, 4 developed acute cholecystitis	To review the complications following TACE for liver tumors
Xue et al[10]	Severe complications were few (4.9%), acute cholecystitis (n = 4 in 511)	A large cohort study of TACE for huge HCC with a diameter over 10 cm
Cosgrove et al[14]	Severe procedure-related complications were seen in 3.2% (cholecystitis, n = 1 in 62 patients)	An open-label study of 62 patients with DEB-TACE for unresectable HCC
Dhamija et al[8]	Biliary complications of various severities developed in 6 (3.6%) patients, leading to an incidence of 1.9% (6/305)	The incidence and presentation of biliary complications following TACE in patients with HCC
Tu et al[7]	The incidence was 2.1% per patient and 0.84% per TAE/TACE procedure. The complications included cholecystitis (n = 2). Major complications are mostly benign, but some are lethal	The incidence and outcome of major complications following conventional TAE/TACE therapy for HCC
Tarazov et al[30]	Serious ischemic complications of TACE occur in about 5% of patients and can be successfully managed without open surgery	The frequency, character, methods of treatment, and outcome of ischemic complications after TACE
Jayakrishnan et al[12]	Hepatic artery-based therapies carry a risk of cholecystitis (0.02%-24%), although the risk is reduced with selective catheterization	Review of the impact of antineoplastic therapies on the risk for cholelithiasis and acute cholecystitis
Malagari et al[26]	Severe procedure-related complications were seen in 4.2% (cholecystitis: n = 1; liver abscess: n = 1; pleural effusion: n = 1)	The results of segmental transcatheter arterial chemoembolization with doxorubicin-loaded DC bead in the treatment of HCC in non-surgical candidates
Biselli et al[23]	A significantly more favorable survival was observed for TACE-treated patients compared with IAC-treated patients; the side effect after the intraarterial procedure was chemical cholecystitis (8%)	TACE and IAC have a primary role in treating patients with unresectable HCC larger than 5 cm
Chen et al[2]	Metaanalysis provides preliminary evidence for the comparative safety and efficacy of HAIC and TACE combined with sorafenib, and indicates the dominance of HAICoxaliplatin in HCC interventional therapy	A systematic review and network metaanalysis of comparative effectiveness of interventional therapeutic modalities for unresectable HCC
Hidaka et al[17]	Combined therapy involving bland GS-TAE followed by Lip-TACE can be performed safely and may improve survival in patients with huge HCCs. Severe adverse events were seen in two patients, acute cholecystitis and tumor rupture (n = 21)	To assess the efficacy of combined therapy involving bland TAE using gelatin sponge particles followed by TACE using lipiodol mixed with anticancer agents and GS particles
Llovet and Bruix[3]	Sensitivity analysis showed a significant benefit of chemoembolization with cisplatin or doxorubicin but none with embolization alone	Systematic review of randomized trials for unresectable HCC, and chemoembolization improves survival
Monier et al[29]	DEB-TACE was associated with increased hepatic toxicities compared to conventional TACE	Comparison between drug-eluting beads and lipiodol emulsion in liver and biliary damages following TACE of HCC
Wagnetz et al[31]	There was a 49% incidence of acute cholecystitis for TACE of HCC, and a lobar TACE of the right hepatic artery likely carries the highest risk of post-TACE cholecystitis	Acute ischemic cholecystitis is self-limiting and does not seem to require any intervention or surgery
Karaman et al[13]	The possibility of cholecystitis is always remembered during TACE-DEB for tumors in segments IV and/or V	A case of ischemic cholecystitis after DEB-TACE that required cholecystectomy
Karavias et al[11]	Super selective embolization significantly reduces the risk of cholecystitis. In most cases, management is conservative and only severe cases require further intervention	Gangrenous cholecystitis related to TACE treatment for HCC
Chung et al[20]	Important predisposing factors were major portal vein obstruction, compromised hepatic functional reserve, biliary obstruction, previous biliary surgery, excessive amount (> 20 mL) of iodized oil, hepatic arterial occlusion after repeated transcatheter oily chemoembolization (TOCE), and nonselective embolization	The major complications and their predisposing factors in TOCE for hepatic tumors
Kim et al[15]	Adjustments in the amounts of iodized oil or gelatin sponge particles and in the sites of embolization may reduce ischemic biliary injuries after TACE	The exact pathogenic mechanisms and clinical implications of the ischemic bile duct injury after TACE in patients with HCC
Song et al[21]	The biliary abnormality prone to ascending biliary infection was the most important predisposing factor to the development of liver abscess after TOCE	The incidence, predisposing factors for, and clinical outcome of liver abscess developing in patients with hepatic tumors after TOCE
Vasudevan et al[9]	The differential diagnosis in a patient with abdominal pain after TACE including post-embolization syndrome and, less commonly, hepatic abscess formation, one must consider cholecystitis especially for right-sided hepatic tumors	A case of acute ischemic cholecystitis following DEB-TACE
Lim et al[22]	The presence of gallbladder perforation must be recognized in patients with persisting symptoms and imaging evidence	A rare but serious complication: Gallbladder perforation following TACE
Kuroda et al[32]	Patients with post-TAE infarction of the gallbladder can be treated conservatively	Gallbladder infarction developing after TAE in patients with malignant hepatic tumors was studied
Sun et al[4]	If a hepatic resection is carried out after TACE, the gallbladder should be removed simultaneously. In addition, once a patient has developed an infarcted gallbladder, a cholecystectomy becomes necessary	The incidence, diagnosis, treatment, outcome, and mechanism of hepatic and biliary damage after TACE for malignant hepatic tumors

Lip-TACE: Lipiodol mixed with anticancer drugs and GS particles; TACE: Transarterial chemoembolization; HCC: Hepatocellular carcinoma; DEB-TACE: Drug-eluting bead transarterial chemoembolization; TAE: Transarterial embolization; IAC: Intraarterial chemotherapy; HAIC: Hepatic artery infusion chemotherapy.