Gastrointestinal and Urinary
Indications
Symptomatic hemangiomas - often large and peripheral. They can cause RUQ pain, nausea, early satiety, and/or jaundice. Rarely they can cause platelet sequestration, DIC, heart failure, or spontaneous rupture.
Large (“giant”) asymptomatic or symptomatic hemangiomas - definitions vary but >5 cm is a common definition to consider treatment. Some also use progressive growth such as >1 cm in 1 year.
Contraindications
Uncorrected severe coagulopathy
Unsafe access
Efficacy and alternatives
Observation - spontaneous rupture is rare, so it is not unreasonable to monitor asymptomatic hemangiomas
Minimally invasive treatments - systematic review
Generally ~100% have symptom resolution even without substantial size reduction
cTACE with bleomycin - 99.9% clinical success, 81.9% radiological success, 0.2% adverse events
Percutaneous bleomycin sclerotherapy - 89.7% clinical success, 81.3% radiological success, 0.8% adverse events
RF or MW ablation - 99.2-99.8% clinical success, 86.2-95.6% radiological success, 1.9-2.1% adverse events
Surgical resection - outcomes vary substantially based on local expertise. Only way to eliminate 100% of the hemangioma but this may not be necessary as noted above. Generally, these are major surgeries with prolonged recovery.
Pre-procedure care
CBC, CMP, INR/PT
Multiphase CT or MRI to characterize as a hemangioma. Biopsy is often unnecessary but can be pursued for indeterminate lesions.
procedure
Ablation approach is similar to other hepatic lesions - see ablation procedure guide.
Chemoembolization
Radial or femoral access
Selective hepatic arteriography. DynaCT can help characterize the arterial anatomy
Further superselection with microcatheter/microwire of choice. Notably, cTACE for hemangiomas generally do not benefit from as selective of delivery compared to HCC.
Treatment - best data seems to support a 1:1 emulsion of 15-60 IU bleomycin in water mixed with lipiodol. 30-45 IU is common with higher doses for larger lesions. Can follow with gelfoam or particle embolization but may be unnecessary. Other treatment options include transarterial ethanol and STS foam sclerotherapy.
Remove catheters and obtain hemostasis.
Percutaneous sclerotherapy
Often US and fluoro guided and faster than chemoembolization
Obtain percutaneous access to central solid appearing portion with a 22G needle under US guidance. Try to course through some normal liver and have tip not within the central “vascular lakes” of the hemangioma.
Inject a small amount of contrast under fluoro to confirm that it stays within the lesion. If it does not, adjust the needle and try again. Having IV tubing on the needle can be helpful.
Inject 1:1 emulsion of 15-60 IU bleomycin in water mixed with lipiodol under fluoroscopic monitoring. 30-45 IU is common with higher doses for larger lesions.
Remove the needle
Complications
Most common are post-embolization syndrome particularly with cTACE or and inflammatory response which can rarely be systemic and respond to steroids and NSAIDs
Rare complications include rupture or bleeding with percutaneous access, vascular injury with TACE. No reported deaths.
Post-procedure care & Follow Up
Often same day outpatient procedure
Follow up visit in 1 month. If no symptom improvement or concern for complication, you can obtain follow up imaging at 1-3 months.
Otherwise, follow up CT or MRI in 6 months
Generally 85% will have <50% size reduction. Treatment can be repeated but this may not be necessary if symptoms have resolved, which do in ~100%.
Additional Resources
Backtable Articles and Podcasts on treatment of giant hepatic hemangiomas