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World J Respirol. Nov 28, 2016; 6(3): 69-75
Published online Nov 28, 2016. doi: 10.5320/wjr.v6.i3.69
Pulmonary complications of transcatheter arterial chemoembolization for hepatocellular carcinoma
Quan M Nhu, Harry Knowles, Paul J Pockros, Catherine T Frenette
Quan M Nhu, Department of Medicine, Scripps Clinic - Scripps Green Hospital, La Jolla, CA 92037, United States
Quan M Nhu, Paul J Pockros, Scripps Translational Science Institute, La Jolla, CA 92037, United States
Harry Knowles, Division of Interventional Radiology, Scripps Clinic - Scripps Green Hospital, La Jolla, CA 92037, United States
Paul J Pockros, Division of Gastroenterology/Hepatology, Scripps Clinic - Scripps Green Hospital, La Jolla, CA 92037, United States
Catherine T Frenette, Scripps Center for Organ Transplantation, Scripps Clinic - Scripps Green Hospital, La Jolla, CA 92037, United States
Author contributions: All authors contributed to this paper with the conception and design of the study, literature review and analysis; Nhu QM and Frenette CT wrote the manuscript; Knowles H and Pockros PJ reviewed and edited the manuscript critically; all authors approved the final version.
Supported by NIH 4KL2TR001112 (to Quan M Nhu).
Conflict-of-interest statement: No conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Catherine T Frenette, MD, Scripps Center for Organ Transplantation, Scripps Clinic - Scripps Green Hospital, 10666 N. Torrey Pines Rd, Suite N200, La Jolla, CA 92037, United States. frenette.catherine@scrippshealth.org
Telephone: +1-858-5544310 Fax: +1-858-5543009
Received: April 26, 2016
Peer-review started: April 27, 2016
First decision: June 17, 2016
Revised: July 27, 2016
Accepted: August 17, 2016
Article in press: August 18, 2015
Published online: November 28, 2016
Abstract

Transcatheter arterial chemoembolization (TACE) is an effective palliative intervention that is widely accepted for the management of hepatocellular carcinoma (HCC). Post-TACE pulmonary complications resulting in acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) are rare events. Pulmonary complications after TACE are thought to be related to chemical injury subsequent to the migration of the infused ethiodized oil or chemotherapeutic agent to the lung vasculature, facilitated by arteriovenous (AV) shunts within the hyper-vascular HCC. We review herein the literature on pulmonary complications related to TACE for HCC. Post-TACE pulmonary complications have included pulmonary oil embolism, interstitial pneumonitis, chemical pneumonitis, ALI, ARDS, lipoid pneumonia, acute eosinophilic and neutrophilic pneumonia, bilious pleuritis, pulmonary abscess, pulmonary tumor embolism, and possibly pulmonary metastasis with HCC. The risk factors associated with post-TACE pulmonary complications identified in the literature include large hyper-vascular HCC with AV shunts, large-volume Lipiodol infusion, and embolization via the right inferior phrenic artery. However, the absence of known risk factors is not a guarantee against serious complications. An astute awareness of the potential post-TACE pulmonary complications should expedite appropriate therapeutic interventions and increase potential for early recovery.

Keywords: Transcatheter arterial chemoembolization, Liver cirrhosis, Pulmonary complications, Hepatocellular carcinoma, Acute lung injury, Acute respiratory distress syndrome, Pneumonitis, Pulmonary oil embolism

Core tip: Pulmonary complications after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) are thought to be related to chemical injury caused by the infused ethiodized oil or chemotherapeutic agent, which can migrate to the lung vasculature via arteriovenous (AV) shunts associated with the hyper-vascular HCC. The risk factors associated with post-TACE pulmonary complications include large hyper-vascular HCC, AV shunts, large volume of Lipiodol, and embolization via the right inferior phrenic artery. However, the absence of known risk factors is not a guarantee against serious complications. Careful monitoring of patients perioperatively and an awareness of the potential post-TACE pulmonary complications should expedite early recognition and effective management of these patients.