Background Complete pathologic necrosis (CPN) at liver transplant is a positive predictor of freedom from recurrence and overall survival for patients with hepatocellular carcinoma (HCC). Comprehensive authorized user parameters for yttrium 90 radiation segmentectomy CPN rates at explant remain undefined. Purpose To evaluate established outcomes for radiation segmentectomy before liver transplant and determine optimal parameters to achieve CPN among patients with treatment-naive HCC. Materials and Methods This multicenter retrospective study included patients with treatment-naive HCC who underwent glass microsphere radiation segmentectomy before liver transplant from January 2016 to December 2024. Treatment parameters were compared for patients that achieved CPN versus those without CPN using Mann-Whitney U or χ2 tests. Receiver operating characteristic analysis was performed to determine treatment parameter thresholds and subsequently predict CPN. Results A total of 303 patients with 364 tumors were included in the study. Tumors had a median size of 2.4 cm (IQR, 2.0-3.1 cm) and demonstrated a CPN rate of 68% (246 of 364). Compared with tumors without CPN, those with CPN had a higher microsphere activity (median, 1242 Bq vs 1203 Bq; P < .03), microspheres per milliliter (median, 9000 per mL vs 7600 per mL; P = .02), single-compartment dose (median, 544 Gy vs 379 Gy; P < .001), and angiosome-to-tumor volume ratio (median, 25.2 vs 15.6; P = .02). Multivariable logistic regression showed that a microsphere activity of 1087 Bq or greater (P = .03), a dose of 440 Gy or greater (P < .001), and an angiosome-to-tumor volume ratio of 16 or greater (P < .001) were independent predictors of CPN. There was a positive association between the number of optimized parameters and CPN at liver transplant, with a positive predictive value of 74% (198 of 269) with one threshold met and 91% (57 of 63) with all thresholds met (P < .001). Conclusion Among patients with treatment-naive HCC, glass microsphere radiation segmentectomy before liver transplant achieved high rates of CPN, which was associated with optimized parameter thresholds determined for microsphere activity, microspheres per milliliter, dose, and angiosome-to-tumor volume ratio. © RSNA, 2026 Supplemental material is available for this article. See also the editorial by Gordon and Lewandowski in this issue.

In this expert opinion, we provide the rationale for concluding that radiation segmentectomy (using the RADSEG method) - a technique involving the transarterial delivery of an ablative, complete necrosis-inducing dose of yttrium-90 radiotherapy - is curative in limited-disease burden hepatocellular carcinoma (HCC). Currently, curative options for early stage and other carefully selected HCC cases include transplantation, resection, and ablation. Because of issues with organ availability, co-morbidities preventing resection, and tumour size and location limiting ablation, other treatments are necessary for this selected patient population. The RADSEG method has evolved into an intra-arterial approach in this setting, with long-term outcomes comparable to ablation, resection, and transplantation. It is proposed that yttrium-90 radioembolisation, applying the RADSEG technique, be formally recognised as curative for early HCC.

In cirrhotic patients, refractory ascites (RA) is a devastating consequence of portal hypertension and is associated with high morbidity and mortality. Over the past quarter century, transjugular intrahepatic portosystemic shunt (TIPS) placement has become a key treatment for patients with RA, but there has been an evolution of patient evaluation, stents, and procedural techniques during this time. As such, the rates of ascites control, survival, and associated hepatic encephalopathy have evolved as well. This review examines the evidence and current recommendations for TIPS in the setting of RA.

The management of traumatic injury of the large veins within the abdomen has continued to evolve with the development of endovascular techniques and the innovation of technology. Operative management of these patients is often difficult due to the anatomic location of these injuries and other associated injuries. Venous injuries can range from acute hemorrhage to complete thrombosis of the vessel, posing high rates of morbidity and mortality. A comprehensive approach to trauma patients, including initial assessment and imaging, is important in detecting injuries to the inferior vena cava or portomesenteric veins and their tributaries. Patient presentation and prognosis are important factors that drive treatment options. This article will review traumatic injuries of the major veins within the abdomen and potential options for endovascular management.

Purpose: Data on the safety and efficacy of external beam radiation therapy (EBRT) after yttrium 90 transarterial radioembolization (TARE) for hepatocellular carcinoma (HCC) are limited. We report our experience using EBRT to treat HCC patients previously treated with TARE. Methods and Materials: We retrospectively analyzed 31 HCC patients who received EBRT following TARE. Eighteen (58%) were treated with photon therapy, and 13 (42%) with proton therapy. Eighteen patients (58%) had been previously treated with TARE within the EBRT-treated lesion, with a median total dose of 72 mCi (range, 49-272). Twenty-one patients (68%) had prior TARE outside the EBRT zone, with a median total dose of 84 mCi (range, 21-330). Toxicities and survival outcomes were analyzed. Results: The number of prior TARE treatments ranged from 1 to 5: 14 patients (45%) received 1, and 17 (55%) received 2 or more. Indications for EBRT included incomplete TARE response (n = 2), technical TARE limitations (n = 25), and other reasons (n = 4). The median tumor size was 3.8 cm (range, 1.6-19.4). Most patients (87%) had a Child-Pugh (CP)-A score. With a median follow-up of 30 months, the 2-year progression-free survival and overall survival rates were 18% and 43%, respectively. The 2-year cumulative incidence of local failure was 7%. CP+2 progression was observed in 4 patients (13%). There was no significant difference in local failure or CP+2 rates based on the EBRT target location relative to prior TARE. Grade 3+ biliary complications occurred in 3 patients (10%): 2 biloma and 1 biliary stricture. All 3 patients had received at least 2 prior TARE treatments that overlapped with the area treated with EBRT and had tumors located near the central bile duct. Conclusions: EBRT for HCC patients previously treated with yttrium 90 is feasible and offers excellent local control. Liver dysfunction and biliary toxicities are potential complications and should be weighed against the clinical benefits.

523 Background: Data on the safety and efficacy of external beam radiation (EBRT) after Yttrium-90 (Y-90) radioembolization for hepatocellular carcinoma (HCC) is limited. We report our experience using EBRT to treat HCC patients who were previously treated with Y-90. Methods: We analyzed 31 HCC patients who received EBRT following Y-90 treatment. Eighteen were treated with photon therapy (40-50 Gy in 5 fractions), and thirteen with proton therapy (42-67.5 Gy in 15 fractions). Twenty-four patients underwent Y-90 segmentectomies, while seven received Y-90 lobar treatment. The median administered Y-90 activity was 44.4 mCi (range 8.3-114.4). Results: Patients had received 1 (n=14), 2 (n=7), or ≥3 (n=10) prior Y-90 treatments. EBRT was administered for various reasons: poor Y-90 response in two patients, technical limitations in 25 patients, and other reasons in four patients. Ten patients had previously received Y-90 within the EBRT area, thirteen outside the EBRT area, and eight in both regions. The median tumor size was 3.8 cm (range 1.6-19.4). Twenty-seven patients had Child-Pugh (CP)-A score, three had CP-B, and one had CP-C baseline liver function. With a median follow-up of 21 months, the 2-year progression-free survival, and overall survival rates were 28%, and 43%, respectively. The 2-year cumulative incidence of local failure was 7%. CP+2 progression was observed in five patients (16%): three had Y-90 delivered outside the EBRT area and two within the EBRT area. Three patients had possible RILD-related deaths. Grade 3+ biliary complications occurred in three patients (10%): one biloma, one liver abscess, and one biliary stricture which resulted in a possible treatment-related death. All three patients had received at least two prior Y-90 treatment overlapping with the area treated with EBRT and had tumors located near the porta hepatis. Conclusions: EBRT for HCC patients previously treated with Y-90 is feasible and offers excellent local control. Hepatic function and biliary toxicities are potential complications and should be weighed against the clinical benefits.

Intraluminal magnetic resonance imaging (MRI) is a promising option to guide interventions, offering several advantages over other imaging modalities. It provides high spatial and contrast resolution for imaging luminal structures, excellent extra-luminal soft tissue visualization, real-time tracking of interventional devices, and operates without ionizing radiation. The applications of intraluminal MRI range from high-resolution imaging of vessel walls to MRI-guided interventions for managing life-threatening conditions such as cardiovascular atherosclerotic disease and malignancies within luminal structures. Clinical use of intraluminal MR technology optimizes endovascular delivery of therapeutics to targeted vessel segments and guides myocardial delivery of stem cells. However, advancements are still required, such as the refinement of MR-compatible interventional devices, development of real-time “MR fluoroscopy” similar to X-ray fluoroscopy, and establishment of safe clinical environments with large bore and short magnets. These improvements are essential for broader clinical adoption of intraluminal MR technology in healthcare.

Radiation-based local-regional therapies for hepatocellular carcinoma (HCC) have gained wide acceptance due to promising rates of tumor response, survival, and safety profiles. After treatment, it is important to assess tumor response to determine further management, patient prognosis, and endpoint outcomes for clinical trials. To standardize imaging interpretation and reporting of HCC response to local-regional treatment, a few imaging-based response assessment systems were developed. Two of them have emerged as the most used: the Liver Imaging Reporting and Data System (LI-RADS) Treatment Response Algorithm (LR-TRA) and the modified Response Evaluation Criteria in Solid Tumors (mRECIST). While these systems have been validated for the assessment of response to ablative locoregional therapies, assessment of response to radiation-based therapies can be challenged by persistent or evolving imaging features and is still an area of active research. Following the advances in technology and a better understanding of tumor biology that allowed for the increased application of radiation-based local-regional therapies for the treatment of HCC, research is still needed to address the limitations of current imaging criteria for assessing tumor response to these novel techniques. In this review, we describe radiation-based liver-directed treatment options, examine imaging criteria for assessing treatment response, discuss practical limitations and gaps in knowledge when applying these response criteria, and address future directions that may help to improve accuracy and outcomes when assessing response to radiation-based HCC treatment.

To the editor, Recurrent hepatocellular carcinoma (r‐HCC) develops in >30% of patients following liver transplantation (LT) and represents a negative predictor of survival.[1] Despite this, r‐HCC after LT lacks an accepted gold‐ standard therapy supported by prospective randomized evidence. Several small studies have examined the role of locoregional therapies (LRTs) in r‐HCC after LT, but there is a lack of studies examining transarterial radioembolization (TARE) in this patient population. This multicenter retrospective study aims to explore the utility of TARE with yttrium‐90 (Y90) for treating patients with r‐HCC after LT.

Hepatocellular carcinoma remains a prominent cause of cancer-related mortality globally. Transarterial yttrium-90 radioembolization is a versatile therapy and plays an important role in the treatment of hepatocellular carcinoma. This review summarizes the establishment of radioembolization in the hepatocellular carcinoma treatment paradigm, treatment considerations across cancer stages, and recent advances in evidence.

Transarterial radioembolization using yttrium-90 (Y-90) microspheres is an important therapy in the management of unresectable primary liver tumors or hepatic metastases. While radioembolization is generally well-tolerated, it is not free from adverse events, and familiarity with the prevention and treatment of radioembolization-specific complications is an important component of patient care. This article aims to review radioembolization-specific toxicities stratified by hepatic, extrahepatic, and systemic effects, with a focus on preventing and mitigating radioembolization-induced morbidity.

PurposeInferior vena cava (IVC) filter tilt may lead to apex embedment and need for advanced retrieval techniques. This study assesses factors associated with filter tilt change over time and need for complex retrieval procedures.Materials and methods252 consecutive patients underwent retrievable IVC filter placement and removal at a single academic institution over 58 months. 182 (72.2%) patients met inclusion criteria. IVC filters included 168 (92.3%) Gunther Tulip and 14 (7.7%) Option filters. The primary outcome was medial-to-lateral IVC filter tilt change between placement and retrieval. Secondary outcomes included advanced retrieval technique use and multiple retrieval attempts. Independent variables included demographics, IVC diameter, filter hook position relative to the renal veins, and dwell time. Associations were determined using student's t-tests, ANOVA, and linear and logistic regressions.ResultsMean IVC diameter at placement was 19.2 ± 3.3 mm. Mean filter tilts at placement and retrieval were 6.1 ± 4.9° and 5.2 ± 5.0°, respectively. Mean tilt change was 5.0 ± 5.0°. Larger IVC diameter was associated with greater filter tilt change (p = 0.0004). While IVC diameter did not independently predict retrieval difficulty, greater tilt change and prolonged dwell time were associated with increased advanced retrieval technique use (p = 0.01 and 0.002, respectively). Results were unchanged in a subgroup analysis of patients treated with Gunther Tulip filters.ConclusionLarger IVC diameter predicts increased filter tilt change, which in turn is associated with challenging retrievals. Attention to IVC diameter during filter placement may anticipate tilt-related complications.

Traumatic injury is the leading cause of death worldwide in younger patient populations and extremity trauma with associated vascular injury accounts for many trauma-related deaths. Iatrogenic injury is also a common cause of extremity vascular trauma and the incidence of iatrogenic injury will likely increase as endovascular techniques continue to become more ubiquitous. For many vascular injuries involving the extremities, surgical repair is viewed as the standard of care. Historically, endovascular techniques did not play a role in the treatment of these vascular injuries, rather they were utilized only as part of the diagnostic assessment; however, there is an increasing trend toward endovascular management of extremity vascular trauma. No validated, widely implemented algorithm to select patients for endovascular intervention exists. Transcatheter techniques, however, play an important role in the management of these patients. For arterial injuries, embolization can be used to rapidly achieve hemostasis if the vessel can be sacrificed. More advanced endovascular techniques such as stent-graft placement may be best employed in the context of isolated, proximal extremity injuries, although there is increasing literature supporting the use of advanced techniques for more distal arterial injuries. The management of peripheral venous trauma remains controversial; however, there is growing data describing successful endovascular management of some peripheral venous injuries. The purpose of this article is to review extremity vascular trauma, concepts of injury triage, endovascular techniques, and intraprocedural considerations.

Background and Aims Locoregional therapies, including yttrium‐90 radioembolization, play an important role in the treatment of unresectable HCC. The aim of the LEGACY (Local radioEmbolization using Glass Microspheres for the Assessment of Tumor Control with Y‐90) study was to evaluate objective response rate (ORR) and duration of response (DoR) in patients with solitary unresectable HCC treated with yttrium‐90 glass microspheres. Approach and Results LEGACY is a multicenter, single‐arm, retrospective study conducted at three sites that included all eligible, consecutive patients with HCC treated with radioembolization between 2014 and 2017. Eligibility criteria included solitary HCC ≤ 8 cm, Child‐Pugh A cirrhosis, and Eastern Cooperative Oncology Group performance status 0‐1. Primary endpoints were ORR and DoR based on modified Response Evaluation Criteria in Solid Tumors in the treated area (localized), as evaluated by blinded, independent, central review. Radioembolization was performed with intent of ablative‐level dosimetry in a selective fashion when possible. Overall survival was evaluated using Kaplan‐Meier and multivariate Cox proportional hazards. Among the 162 patients included, 60.5% were Eastern Cooperative Oncology Group 0, and the median tumor size was 2.7 cm (range: 1‐8) according to blinded, independent, central review. Radioembolization served as neoadjuvant therapy for transplantation or resection in 21.0% (34 of 162) and 6.8% (11 of 162) of patients, respectively, and as primary treatment for all others. Median follow‐up time was 29.9 months by reverse Kaplan‐Meier. ORR (best response) was 88.3% (CI: 82.4‐92.4), with 62.2% (CI: 54.1‐69.8) exhibiting a DoR ≥ 6 months. Three‐year overall survival was 86.6% for all patients and 92.8% for those neoadjuvant patients with resected or transplanted liver. Conclusions In this multicenter study of radioembolization, clinical meaningful response rates and prolonged DoR were observed in the treatment of unresectable, solitary HCC ≤ 8 cm.

300 Background: The objective of the LEGACY study was to assess the Objective Response Rate (ORR) and Duration of Response (DoR) following treatment with Yttrium-90 (Y90) glass microspheres in patients with unresectable solitary hepatocellular carcinoma (HCC). The objective of the analyses presented here are to evaluate ORR, DoR, and Overall Survival (OS) by transplant/resection status and to compare these outcomes with patients who did not go on to transplantation/resection after receiving treatment with Y90. Methods: LEGACY is a single-arm, multicenter, retrospective study of patients with unresectable HCC who received treatment with Y90 glass microspheres (TheraSphere) at one of three sites in the United States. LEGACY included all consecutive eligible patients who received treatment between January 2014 and December 2017 and met the eligibility criteria (Child-Pugh A; ECOG score of 0 or 1; BCLC A or C; and a solitary tumor > 2 and ≤8 cm). Primary efficacy endpoints included ORR and DoR. ORR included patients who achieved either a complete response or partial response based on localized mRECIST; response was assessed via blinded, independent, central review. Secondary endpoints include OS and number and type of subsequent treatments, including transplantation and resection. Results: Among all 162 patients enrolled in LEGACY, ORR was 72.2% (117/162; 95% CI = 64.9%, 78.5%); the majority of patients experienced DoR ≥ 6 months (89/117, 76.1%, 95% CI = 67.6%, 82.9%). Median follow-up time for all 162 patients enrolled in LEGACY was 29.9 months by reverse Kaplan-Meier analysis; 3-year OS was 86.6%. For 45/162 (27.8%) of patients, Y90 treatment served as neoadjuvant therapy; 34 went on to transplantation (21.0%) and 11 (6.8%) went on to resection. For neoadjuvant treatment, ORR was 80.0% (36/45, 95% CI = 66.2, 89.1), DoR ≥ 6 months was 30.6% (11/45, 95% CI = 18.0, 46.9), and 3-year OS was 92.8% (95% CI = 74.2, 98.2). Of these 45 patients, 35 patients achieved complete response (CR), 1 achieved partial response (PR), and 9/45 (20.0%) were deemed not evaluable as they underwent surgery prior to the 6-month mark and did not have imaging assessments post-Day 46. These nine patients were censored, lowering the DoR; however, histopathology revealed that 7/9 (77.8%) achieved complete pathologic necrosis, 1/9 (11.1%) had extensive pathologic necrosis, and 1 (11.1%) had partial pathologic necrosis. For the 117/162 (72.2%) patients who did not go on to surgical treatment, ORR was 91.5% (107/117, 95% CI = 85.0, 95.3), DoR ≥ 6 months was 72.9% (78/117, 95% CI = 63.8, 80.4), and 3-year OS was 83.5% (95% CI = 72.2, 90.5). Conclusions: Treatment of solitary unresectable HCC with Y90 glass microspheres provides strong ORR, DoR, and OS both as neoadjuvant therapy to transplantation/resection and as treatment in non-surgical candidates.

Hepatic artery aneurysms (HAA) are rare and may be seen in the setting of infection and vascular disease. Clinical presentation is variable but many are found incidentally during imaging studies. The association of HAA with focal nodular hyperplasia (FNH) is rarely reported in literature. We present the case of a 68-year-old woman found to have a hepatic artery aneurysm and hepatic mass, both within the same liver segment. FNH and hepatic adenomas share similar imaging features but have different treatments due to malignant potential of the latter, and biopsy should be performed when adenoma cannot be excluded. In this case biopsy of the mass revealed it to be FNH and the aneurysm was treated with embolization rather than surgery.

481 Background: We sought to identify predictors of progression of LR3 lesions (i.e. indeterminate for HCC) to LR5 lesions (i.e. definitely HCC) on follow-up imaging among cirrhotic pts. Methods: Imaging reports with LR assignments were identified among pts seen at the University of Washington, 2013-2017. Cirrhotic pts with a LR3 lesion and follow-up scan within 1 year (yr) of LR3 lesion date were included (n = 313). Clinical features were abstracted from chart review. Survival analyses employing interval censoring were performed. Variables as potentially predictive of LR3 progression were identified in univariate analyses, with backwards elimination done (p < 0.05) to obtain the final multivariate model. Results: 20.4% of LR3 lesions progressed to LR5 within 1 yr; 73% were still LR3, 8% progressed to LR4. The population was predominantly male (61%), Caucasian (71%), older than 55 (63%). The most common cirrhotic etiologies were HCV (46.7%), alcohol (32.6%), and NASH (12.8%), not mutually exclusive. AFP at the time of LR3 scan was low if available (39% with AFP <5, 16% 5-10, 28% unknown). 22.7% had impaired liver function (ALBI grade 3); 19.5% lacked data to calculate ALBI grade. CT scan was the most common exam (56%). Multiple LR3 lesions were seen on 51% of scans. Most LR3 lesions were right sided (75%), < 1 cm (51%); 7% of lesions were > 2cm. Men (HR 2.0, p = 0.02), earlier scan yr (HR 0.47 per yr, p < 0.0001), older age (HR 1.42 per 15 yr, p = 0.047), lesion size (HR 1.21 for 2cm+, global p = 0.02) appeared as independent predictors of LR3 to LR5 progression based on the final model. Of 16 variables examined, men were more likely to have chronic HCV, history of alcohol use and less likely to have autoimmune hepatitis. No other differences were seen. In an a priori analysis, risk of male sex (HR 1.99, p = 0.03) persisted despite control for HCV, alcohol, age, race, scan yr, lesion size, and number of lesions. Conclusions: Identification of clinical factors associated with LR3 progression may allow for risk modeling tools that may assist in determining imaging frequency and timing of intervention. The increased risk among men vs women is not explained by clinical or radiographic features listed above.

Background Isolated persistent left superior vena cava (PLSVC) is a rare vascular anatomic variant, which can be an incidental finding at the time of an endovascular procedure. Case presentation This report describes the technical success, adverse events, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation via isolated PLSVC. Three adult patients with cirrhosis and isolated PLSVC underwent TIPS placement successfully with one major adverse event. Two patients required TIPS revision within 90 days. There were no deaths within 90 days. Conclusions TIPS creation via isolated PLSVC is feasible using standard techniques with a left jugular vein approach. Caution is warranted during the procedure to assess for any aberrant drainage pattern to the left atrium and to prepare for potentially challenging instrument navigation through the coronary sinus.