Lipiodol ultrafluido

The TACE was performed by two operators who respectively had at least 8 years and 20 years of experience in performing this type of procedures. Initially, the tip of a 5-French catheter (Cook, Bloomington, IN, USA) or 3-French microcatheter (Progreat, Terumo, Tokyo, Japan) was advanced into the tumor-feeding arteries. Then, an emulsion was prepared by mixing 1 part of lipiodol (Lipiodol Ultrafluido, Guerbet, Villepinte, France) and 2 parts of doxorubicin hydrochloride (Hisun Pharmaceutical Co. Ltd., Zhejiang, China). Depending on the liver function and the tumor size, 5-10 ml of the emulsion was injected through the catheter into the tumor-feeding arteries. Lastly, the embolization with gelatin sponge seeds (300–700 μm, Cook) was performed until the stasis of arteries flow was achieved.

TACE was performed according to our institutional standard protocol and has been previously reported (30 (link), 31 (link)). All operators had at least eight years of experience in performing TACE procedures. TACE was performed using transfemoral arterial access route with a micro-puncture system by placing a 5F vascular introducer (Cook, Bloomington, Indiana, USA) and celiac or superior mesenteric arteriography was carried out to assess the arterial anatomy, tumor supplying vessel and patency of the portal vein. A 2.6-Fr microcatheter (Terumo, Japan) was inserted into the tumor donor arteries as superselectively as possible to identify the staining and arteries feeding the target lesions. First, an emulsion of 5-20 mL lipiodol (Lipiodol Ultrafluido, Guerbet, France) mixed with 20-60 mg doxorubicin hydrochloride (Hisun Pharmaceutical Co. Ltd., Zhejiang, China) was injected into tumor feeding branch of the hepatic artery. Then the gelatin sponge particles (300–500 um, Cook, Bloomington, Indiana, USA) mixed with contrast material were administered into the tumor-feeding arteries until stasis of the arterial flow was achieved.

TACE procedures were performed by three experienced radiologists with a minimum of 10 years of experience in interventional therapy. A 5 F catheter (Cook, Bloomington, IN, USA) was inserted into the hepatic artery. Then, a 3F micro-catheter (Progreat, Terumo, Tokyo, Japan) was used to insert the tumor-feeding arteries. Subsequently, lipiodol (Lipiodol Ultrafluido, Guerbet, Villepinte, France) was mixed with doxorubicin hydrochloride to create an emulsion at the ratio of 1 mL/2 mg. Depending on the size of the tumor and liver function, 5–20 mL emulsion was injected slowly into the tumor-feeding arteries until stasis of the feeding arteries of the tumor. If it was necessary, supplement embolization was performed using gelatin sponge particles (300–700 um, Cook, USA).

TACE was performed under local anesthesia via right femoral artery. The Seldinger technique and angiography were performed to identify the tumor-feeding arteries and assess the tumor burden. According to the tumor burden, 5-15mL of emulsion containing 10-20 mg of doxorubicin hydrochloride (Hisun Pharmaceutical Co.LTD, Zhejiang, China) was mixed with 5-10 mL of lipiodol (Lipiodol Ultrafluido, Guerbet, France) and injected into the tumor-feeding arteries through a 3-F microcatheter. Finally, an appropriate amount of gelatin sponge particles (350-560 µm; Cook) was injected into the tumor-feeding arteries to induce embolization.
TKIs including sorafenib (800 mg), lenvatinib (8 or 12 mg), and apatinib (500 mg) were administered orally daily. ICI immunotherapy with intravenous fixed-dose camrelizumab (200 mg) was performed every 3 weeks until disease progression or unexpected toxicity was observed. The dose and interval of TKIs were adjusted according to the toxicity and disease conditions. The administration of TKIs and ICIs should be stopped when unacceptable toxicity occurred or no clinical benefits were observed. What’s more, TKIs and ICIs were discontinued for 3 days before and after TACE.