Purpose : Nonocclusive hepatic artery hypoperfusion syndrome (NOHAHS)—formerly splenic artery steal syndrome—is an underrecognized complication following liver transplantation characterized by arterial insufficiency despite hepatic artery patency. The pathogenesis is driven by maladaptation of the hepatic arterial buffer response (HABR) rather than true steal. This study evaluates the hemodynamic and clinical sequelae of splenic artery embolization (SAE) for NOHAHS. Methods : Twelve patients with graft dysfunction without an alternative cause, patent hepatic artery with elevated resistive index (RI) or slow end-diastolic flow, and dominant splenic circulation were included in this single-center retrospective study. Hemodynamic parameters were calculated using Doppler-derived flow measurements, including hepatic artery flow (HAF), portal vein flow (PVF), and HAF:PVF buffer ratios. Hepatic function biomarkers were assessed up to 12 months post-SAE. Results SAE significantly improved HAF (mean HAF: 91.0 ± 58.0 to 162.4 ± 133.4 mL/min; RI: 0.79 ± 0.10 to 0.72 ± 0.09; P<0.01) while simultaneously reducing PVF (mean PVF: 1,768.5 ± 824.4 to 1,021.6 ± 520.0 mL/min; P<0.01), resulting in a 2.7-fold increase in the buffer ratio (HAF:PVF ratio: 0.068 to 0.190; P<0.01). Sustained improvements in serum bilirubin and albumin were observed after SAE (P<0.05). Procedure-related complications included two cases of non-occlusive splenic vein thrombosis and one splenic abscess. Conclusion : SAE enhances the HABR via reciprocal modulation of hepatic artery and portal vein inflow to improve graft function in NOHAHS. These findings strengthen the HABR theory of graft inflow modulation and support the effectiveness of SAE as a treatment for NOHAHS in the post-transplant period.

Background/Objectives: The integration of locoregional and systemic therapies represents a promising strategy in hepatocellular carcinoma (HCC). Yttrium-90 (Y-90) radioembolization provides durable local tumor control, while immune checkpoint inhibitors (ICIs) improve systemic disease outcomes. This review evaluates the biological rationale, clinical evidence, and emerging role of combination Y-90 radioembolization and immunotherapy in HCC. Methods: A semi-systematic (PRISMA-informed) literature review of PubMed/MEDLINE through September 2025 was conducted, including clinical trials, retrospective and prospective studies, and translational investigations evaluating Y-90 radioembolization, immunotherapy, and their combination. Results: Preclinical and translational studies demonstrate that Y-90 radioembolization induces immunogenic cell death, enhances antigen presentation, and activates immune pathways including interferon signaling and STING-mediated responses, supporting a mechanistic basis for potential synergy with ICIs. Early clinical studies, including phase I/II trials, report objective response rates ranging from approximately 30% to 41.5% and median overall survival up to 20.9 months in selected populations. Treatment-related grade ≥ 3 adverse events range from 10% to 25%, comparable to monotherapy approaches. However, outcomes vary across heterogeneous patient populations, and cross-trial comparisons remain limited. Ongoing prospective trials are evaluating combination strategies incorporating contemporary first-line regimens, including atezolizumab plus bevacizumab and the STRIDE regimen. Conclusions: Combination Y-90 radioembolization and immunotherapy demonstrates a strong biological rationale and encouraging early clinical signals, with acceptable safety profiles. However, current evidence remains preliminary and derived from non-randomized studies. Ongoing randomized trials are required to define optimal patient selection, treatment timing, and sequencing, and to establish whether combination therapy provides meaningful benefit over current standards of care.

PURPOSE:To determine whether older adults with early-stage hepatocellular carcinoma (HCC) and Child-Pugh Class A cirrhosis derive additional survival benefit from orthotopic liver transplantation (OLT) following complete percutaneous thermal ablation (TA). MATERIALS AND METHODS:This study reviewed 98 patients aged 60-80 years with very-early-stage or early-stage HCC (Barcelona Clinic Liver Cancer 0/A) and Child-Pugh Class A cirrhosis, treated between 2011 and 2020, who had complete response to TA at 6 months. Patients were stratified by whether or not they underwent subsequent OLT. Primary outcomes were overall survival (OS) and cancer-specific survival (CSS) at 5 and 10 years. Intention-to-treat, subgroup, and multivariate and time-varying Cox regression analyses were performed. RESULTS:No statistically significant differences in OS (P = .075) or CSS (P = .49) were observed between OLT and non-OLT groups. Five-year OS was 92.0% (OLT) versus 81.2% (non-OLT), and 10-year OS was 81.2% versus 61.9%. Five-year CSS was 100.0% (OLT) versus 92.3% (non-OLT), and 10-year CSS was 89.1% versus 86.3%. Intention-to-treat analysis showed no difference between groups (P = .76), with 5-year OS of 85.1% (OLT waitlisted) versus 83.5% (nonwaitlisted), and 10-year OS of 71.0% versus 66.6%. In time-varying Cox regression analysis, transplantation was not significantly associated with OS (P = .24). CONCLUSIONS:For older adults with early-stage HCC and well-compensated cirrhosis who undergo successful TA, no statistically significant survival advantage was detected for those who received subsequent OLT compared with active surveillance.

This brief report describes a unique case in which distal splenic embolization was achieved by traversing a previously placed coil pack in the proximal splenic artery. Following orthotopic liver transplantation, A 65-year-old woman developed poor hepatic arterial flow which was initially managed by proximal splenic artery coil embolization to improve hepatic perfusion. Her postoperative course also notable for persistent thrombocytopenia and splenomegaly. Distal splenic access was obtained by crossing the previously placed coil pack with a hydrophilic wire which enabled successful distal administration of liquid embolic. This report highlights the feasibility of crossing a coil pack with a wire to facilitate targeted re-embolization.

BACKGROUND & AIMS:Noninvasive variceal risk stratification systems have not been validated in patients with hepatocellular carcinoma (HCC), which presents logistical barriers for patients in the setting of systemic HCC therapy. We aimed to develop and validate a noninvasive algorithm for the prediction of varices in patients with unresectable HCC. METHODS:We performed a retrospective cohort study in 21 centers in the United States including adult patients with unresectable HCC and Child-Pugh A5-B7 cirrhosis diagnosed between 2007 and 2019. We included patients who completed an esophagogastroduodonoscopy (EGD) within 12 months of index imaging but before HCC treatment. We divided the cohort into a 70:30 training set and validation set, with the goal of maximizing negative predictive value (NPV) to avoid EGD in low-risk patients. RESULTS:We included 707 patients (median age, 64.6 years; 80.6% male; 74.0% White). Median time from HCC diagnosis to EGD was 47 (interquartile range, 114) days, with 25.0% of patients having high-risk varices. A model using clinical variables alone achieved an NPV of 86.3% in the validation cohort, whereas a model integrating clinical and imaging variables had an NPV 97.4% in validation. The clinical and imaging model would avoid EGDs in more than half of low-risk patients while misclassifying 7.7% of high-risk patients. CONCLUSIONS:A model incorporating clinical and imaging data can accurately predict the absence of high-risk varices in patients with HCC and avoid EGD in many low-risk patients before the initiation of systemic therapy, thus expediting their care and avoiding treatment delays.

Background & Aims: CARTO and PARTO are well-accepted treatment for gastric variceal (GV) bleeding. However, long-term (>2 years) clinical outcomes have yet to be studied. In this study, we investigated long-term clinical outcomes, including overall survival (OS) in 10 years Methods: We performed a multi-national, multi-center, retrospective study of CARTO/PARTO in GV treatments between 05/2012 and 07/2024. The primary study outcomes were a long-term OS and prognostic factors of CARTO/PARTO. The secondary outcomes were long-term clinical/technical success, complications, clinical changes including portal hypertensive symptoms. Results: A total of 311 patients (41% female; 69% CARTO) from 13 centers in five countries were included. The cumulative 1-, 3-, 5-, 7-, and 10-year OS rates were 98, 80, 68, 52, and 33%, respectively, with a median OS of 99 months. Prophylactic CARTO/PARTO showed a better OS than CARTO/PARTO for active bleeding ( p =0.00035). The independent prognostic factors of OS were having high pre-MELD, concurrent HCC, treating GOV2, history of esophageal variceal bleeding, high pre-TBili, and ammonia levels. Notably, a high pre-MELD score >27 had a significantly higher mortality rate (92.6%) than a lower pre-MELD score ( p <0.001). The overall cumulative 1-, 3-, 5-, 7-, and 10-year recurrent GV bleeding rates were 0.9, 3.2, 4.0, 4.5, and 5.4%, respectively. The overall technical and clinical success rates were 96.5% and 95.3%, respectively, with a 4.5% major complication rate over 10 years. Conclusions: CARTO and PARTO have excellent long-term survival and clinical outcomes. However, these are negatively affected by high MELD scores, concomitant HCC, and coexisting esophageal varices.

PURPOSE:To evaluate factors contributing to technical failure in stent placement for malignant portal vein (PV) occlusion from pancreatic and biliary malignancies and compare effectiveness and safety of bare-metal stents (BMSs) and stent grafts (SGs). MATERIALS AND METHODS:The study included 69 patients with malignant PV occlusion who underwent 74 stent placement procedures between January 2018 and March 2023. Clinical and laboratory parameters were compared between technical success (n = 64) and failure (n = 10) cases and between BMS (n = 48) and SG (n = 16) groups. Clinical success, stent patency, and overall survival (OS) were compared between the 2 groups. Risk factors for stent occlusion and procedure-related adverse events were evaluated. RESULTS:Technical success rate was 86.5%. History of radiotherapy (P = .045) and longer occlusion lengths (>4 cm) (P < .001) were associated with failure. The SG group demonstrated higher clinical success (93.8% vs 64.6%, P = .021) and lower recurrence of portal hypertension-related clinical manifestations (20.0% vs 80.6%, P < .001) compared with the BMS group. Cumulative patency at 1, 3, and 6 months was higher for SG (93.8% vs 64.6%, P = .025; 92.8% vs 51.4%, P = .006; and 90.0% vs 52.2%, P = .038; respectively). Stent type (BMS vs SG) was independently associated with occlusion in multivariable analysis (hazard ratio, 4.79; 95% CI, 1.08-21.01; P = .043). OS did not differ significantly. CONCLUSIONS:Patients with history of radiotherapy and longer length of occluded PV were at higher risk of technical failure in PV stent placement. SG could contribute to a better quality of life owing to its potential benefits in clinical success and stent patency while maintaining safety.

PURPOSE:To characterize the relationship between ablation zone volume (AZV) and microwave ablation (MWA) energy in an in vivo porcine liver model following arterial embolization. MATERIALS AND METHODS:With Institutional Animal Care and Use Committee (IACUC) approval, 11 female swine underwent either right (n = 5) or left (n = 6) hepatic artery embolization under fluoroscopic guidance. Subsequently, ultrasound (US)-guided MWA was performed in each liver segment (left lateral, left medial, right medial, and right lateral) at either 30 W (n = 4 lobes), 60 W (n = 4), 65 W (n = 20), 90 W (n = 8), 120 W (n = 4), or 140 W (n = 4) continuously for 5 minutes. Postprocedural volumetric segmentation was performed on standardized multiphase T1 magnetic resonance (MR) imaging sequences. RESULTS:Mean AZVs in embolized lobes (15.8 mL ± SD 10.6) were significantly larger than those in nonembolized lobes (11.2 mL ± SD 6.5, P < .01). MWA energy demonstrated significant positive linear correlation with both embolized (R2 = 0.66, P < .01) and nonembolized (R2 = 0.64, P < .01) lobes. The slope of the linear models corresponded to a 0.95 mL/kJ (SD ± 0.16) and 0.54 mL/kJ (SD ± 0.09) increase in ablation volume per applied kilojoule of energy (E) in embolized and nonembolized lobes, respectively. In the multivariate model, embolization status significantly modified the relationship between E and AZV as described by the following interaction term: 0.42∗E∗(embolization status) (P = .031). CONCLUSIONS:Linear models demonstrated a near 1.8-fold increase in ratio of AZV per unit E, R(AZV:E), when applied to embolized lobes relative to nonembolized lobes. Absolute AZV differences between embolized and nonembolized lobes were greater at higher-power MWA.

Ectopic varices are rare but potentially life-threatening conditions usually resulting from a combination of global portal hypertension and local occlusive components. As imaging, innovative devices, and interventional radiologic techniques evolve and are more widely adopted, interventional radiology is becoming essential in the management of ectopic varices. The interventional radiologist starts by diagnosing the underlying causes of portal hypertension and evaluating the afferent and efferent veins of ectopic varices with CT. If decompensated portal hypertension is causing ectopic varices, placement of a transjugular intrahepatic portosystemic shunt is considered the first-line treatment, although this treatment alone may not be effective in managing ectopic variceal bleeding because it may not sufficiently resolve focal mesenteric venous obstruction causing ectopic varices. Therefore, additional variceal embolization should be considered after placement of a transjugular intrahepatic portosystemic shunt. Retrograde transvenous obliteration can serve as a definitive treatment when the efferent vein connected to the systemic vein is accessible. Antegrade transvenous obliteration is a vital component of interventional radiologic management of ectopic varices because ectopic varices often exhibit complex anatomy and commonly lack catheterizable portosystemic shunts. Superficial veins of the portal venous system such as recanalized umbilical veins may provide safe access for antegrade transvenous obliteration. Given the absence of consensus and guidelines, a multidisciplinary team approach is essential for the individualized management of ectopic varices. Interventional radiologists must be knowledgeable about the anatomy and hemodynamic characteristics of ectopic varices based on CT images and be prepared to consider appropriate options for each specific situation. ©RSNA, 2024 Supplemental material is available for this article.

Objective: The aim of this study was to analyze the origins of prostatic arteries (PAs) in the Korean population and compare them with those reported in the literature. Materials and Methods: From April 2018 to February 2024, 108 male (mean age +/- standard deviation: 71.6 +/- 9.7 years) with lower urinary tract symptoms (n = 102) or refractory hematuria (n = 6) underwent prostatic artery embolization (PAE). Computed tomography and angiography images were retrospectively reviewed. The branching pattern of the internal iliac artery (IIA) was classified according to the Yamaki system. The origin of the PA was categorized using the de Assis definition, and the incidence of each type was recorded. A systematic literature review was conducted and the most common types of PA were investigated. Results: PAE was successfully implemented on 211 of the 216 pelvic sidewalls. PA cannulation failed in five sidewalls due to a steno-occlusive state. The most common IIA type was type A, in which the IIA was divided into the superior gluteal artery and gluteal-pudendal trunk (77%). Of 226 PAs analyzed, including 15 in 211 sidewalls exhibiting dual PAs, the most common PA origin was the internal pudendal artery (type IV, 35%), followed by the superior vesical (type I, 25%) and obturator (type III, 21%) arteries. Anterior division of IIA (type II) was less common (10%). Type V (uncommon origins) occurred in 8% of cases, including five distal internal pudendal arteries, four quadfurcations, three inferior gluteal arteries, three trifurcations, two medial femoral circumflex arteries, and two rectal arteries. Two of the five patients with surgically or endovascularly altered anatomy were successfully treated via PAs originating from the medial femoral circumflex arteries. Globally, type I is the most common PA type. Conclusion: In the Korean population, the most common IIA pattern and PA origin were types A and IV, respectively.

Background: To evaluate the safety and effectiveness of a stepwise interventional strategy for the removal of adherent totally implanted central venous access port catheters, consisting of a guidewire support, antegrade coaxial separation, and retrograde coaxial separation with increasing technical complexity. Methods: This study has a retrospective design. Thirty-two patients who had failed routine removal of the port catheter and were then transferred to interventional radiology between November 2017 and December 2023 were reviewed. The technical success and complication rates were recorded. Results: All adherent catheters were successfully removed without catheter fragmentation, using guidewire support ( n = 21), antegrade coaxial separation ( n = 5), and retrograde coaxial separation ( n = 6). The technical success rate was 100%, and no complications occurred. Conclusions: The proposed stepwise interventional strategy successfully removed adherent port catheters, with good safety and high effectiveness. It appeared to reduce the incidence of catheter fracture during the removal of adherent totally implantable central venous access port catheters.

Purpose: The objectives of this study were to assess the utility of dynamic contrast-enhanced magnetic resonance (MR) imaging in quantifying parenchymal perfusional changes after embolization and to characterize the association between pharmacokinetic (PK) parameters and final microwave ablation volume.Materials and Methods: PK parameters from dynamic contrast-enhanced MR imaging were used to quantify perfusional changes in the liver after transarterial embolization of the right or left lobe in a swine liver model (n = 5). Each animal subject subsequently underwent microwave ablation (60 W for 5 minutes) of the embolized and nonembolized liver lobes. Changes in PK parameters from dynamic contrast-enhanced MR imaging were correlated with their respective final microwave ablation volumes in each liver lobe.Results: Microwave ablation volumes of embolized liver lobes were significantly larger than those of nonembolized liver lobes (28.0 mL & PLUSMN; 6.2 vs 15.1 mL & PLUSMN; 5.2, P < .001). PK perfusion parameters were significantly lower in embolized liver lobes than in nonembolized liver lobes (Ktrans = 0.69 min-1 & PLUSMN; 0.15 vs 1.52 min-1 & PLUSMN; 0.37, P < .001; kep = 0.69 min-1 & PLUSMN; 0.19 vs 1.54 min-1 & PLUSMN; 0.42, P < .001). There was a moderate but significant correlation between normalized kep and ablation volume, with each unit increase in normalized kep corresponding to a 9.8-mL decrease in ablation volume (P = .035).Conclusions: PK-derived parameters from dynamic contrast-enhanced MR imaging can be used to quantify perfusional changes after transarterial embolization and are directly inversely correlated with final ablation volume.

Immunotherapies for cancer treatment are designed to mobilize a patient’s own immune system against their malignancy locally and systemically. Percutaneous ablation techniques have the potential to work in conjunction with modern immunotherapies by priming the patient’s own lymphocytes to attack previously untreated cancer cells. This phenomenon, known as the abscopal effect, has garnered interest because of the potential for locoregional therapies to induce local and systemic anti-tumor effects and shrinkage of distant tumors (Fionda, 2020). The goal of this study is to evaluate the anti-tumor immune response to irreversible electroporation (IRE) compared with microwave (MWA) and cryoablation in an immunocompetent Oncopig liver tumor model of hepatocellular carcinoma. In-situ liver tumors were induced in a transgenic immunocompetent porcine liver model (2-4 tumors in each liver) with Cre-recombinase induced TP53 and KRAS mutations (Oncopig). Oncopigs were separated into three treatment groups (n = 2), each undergoing either MWA, cryoablation or IRE treatment of a single liver tumor under US or CT guidance. Pre-, immediate post- and 1-week post ablation imaging was performed to evaluate treated and non-treated tumor growth. At each time point, venous blood was also drawn and assayed for critical cytokines related to anti- or pro-tumor immune response. Systemic cytokine levels were correlated to targeted and off-targeted tumor volumes after each time point. Liver tumors were induced at an 83.3% (20/24) success rate. Treated tumors decreased by an average 7% in volume across all treatment modalities on 1-week follow-up imaging. Off-target tumors increased by volume by 71.7% with IRE, 13.6% with MWA and 1.4% with cryoablation. On 1-week blood samples, IRE treated pigs demonstrated lower circulating concentrations of pro-inflammatory IL-2 cytokines when compared with cryoablation (10.9 vs 40.7 pg/mL; P = 0.051). There was no difference in IL-2 levels between MWA and cryoablation-treated pigs (40.7 vs 42.4 pg/mL; P = 0.97). The pro- and anti-tumor immune response is dependent on the type of ablation modality. IRE had the lowest levels of inflammatory marker IL-2 and the lowest degree of tumor control in off target tumors at the one-week time point. Modulating inflammatory pathways via these cytokines after IRE may potentially play a role in amplifying the abscopal effect in liver tumors.