Hepatic Artery Occlusion

　　1. Etiology

　　The causes of hepatic artery occlusion may include embolism, thrombosis, external compression, vessel wall thickening, and iatrogenic factors. Serosal polyarteritis nodosa, emboli from subacute endocarditis, inflammation, tumor infiltration, and injury to the hepatic artery can lead to thrombosis; external infiltration and compression by malignant tumors; vessel wall thickening, intimal damage, proliferation, or shedding, secondary thrombosis, and accidental ligation during surgery can also cause hepatic artery occlusion. In recent years, with the popularization of interventional techniques, the number of cases with hepatic artery embolism during catheter angiography or interventional embolization treatment has increased. Therefore, strict selection of indications and strict technical operation specifications should be ensured to minimize accidents and adverse consequences.

　　2. Pathogenesis

　　The consequence of hepatic artery occlusion is liver infarction. If portal vein occlusion occurs simultaneously, it is often fatal. The mortality rate of hepatic artery occlusion in normal liver is higher than that in patients with liver cirrhosis. The size of liver infarction depends on the range of collateral arterial circulation. The central area of the lesion is pale, with congestion and hemorrhage around it: a large number of necrotic liver cells are seen in the central area. Although there is liver cell necrosis around, there are no significant changes in the portal area, and the liver cells within the infarction area are disordered and irregular.

　　1. Post-embolism syndrome

　　The vast majority (>90%) of THACE patients after surgery experience anorexia, gastrointestinal discomfort, nausea, vomiting (12.3%), fever (70.6%~96%, 38~39℃), lasting for 1-2 weeks, or even 1 month. Right upper quadrant abdominal pain (46%) and paralytic intestinal obstruction may also occur. Severe cases may exhibit pale complexion, slow pulse, cold extremities, excessive sweating, and a drop in blood pressure immediately or shortly after embolism. Generally, symptomatic treatment is given, which can gradually restore normalcy.

　　2. Complications related to chemotherapy drugs

　　1. Myocardial lesions caused by cardiac toxicity

　　Commonly seen after THACE surgery with anthracycline chemotherapy drugs, especially doxorubicin (ADM, 30% with a total dose of 600mg/m2, about 50% with >1000mg/m2), severe cases may develop heart failure. A small number of patients using high doses of CTX and 5-FU may also experience myocardial injury. Once myocardial injury occurs, the first measure should be bed rest, low-sodium diet, and electrocardiographic monitoring, timely administration of myocardial nutrition drugs, and continuous low-flow oxygen inhalation.

　　2, Suppression of bone marrow hematopoietic function

　　The hematopoietic function of the bone marrow is suppressed after interventional chemotherapy, manifested as leukopenia, and platelets and red blood cells are also affected to varying degrees, with severe cases showing a decrease in whole blood. It is common after the application of mitomycin C (MMC), ADM, cisplatin (CDDP), or carboplatin (BP).

　　3, Gastrointestinal toxicity reaction

　　The incidence rate of mucosal damage of the gastrointestinal tract is, manifested as discomfort in the stomach, nausea, vomiting, stomatitis, and diarrhea, which is due to some chemotherapy drugs or embolic agents entering or refluxing into the gastroduodenal artery during the embolization process. It is common during the operation of THACE using fluorouracil (5-FU), CDDP, MMC, and ADM, and is related to the dose. Antacids and antiemetics (such as famotidine and metoclopramide) can often alleviate the symptoms, and it is necessary to stop chemotherapy immediately and replenish fluid to regulate the balance of water and electrolytes.

　　Three, Complications related to instrument operation

　　1, Intimal injury and stripping of the hepatic artery

　　The incidence rate is as high as 34.3% (by procedure), and also reaches 1.5% (by case). High-risk factors:

　　(1) Damage to the normal structure of the arterial wall, such as atherosclerosis.

　　(2) Abnormal curvature or course of the artery, such as atherosclerosis or pressure from a large liver tumor.

　　(3) Arterial wall injury due to excessive roughness or repeated insertion of guide wires/catheters during catheterization; most have no corresponding clinical symptoms.

　　2, Liver artery stenosis or occlusion

　　The incidence rate is 2.9% to 7.7% (by case) or 0.4% (by procedure). High-risk factors:

　　(1) Same as 'intimal injury and stripping of the hepatic artery'.

　　(2) Liver artery with small development.

　　(3) Spasm and occlusion of the blood vessel due to stimulation by interventional therapy, if the operation is continued forcibly, it may cause vascular injury and permanent occlusion. Those with any of the three high-risk factors are prone to thrombosis in the hepatic artery after THACE surgery, which may lead to stenosis or occlusion of the lumen.

　　Clinical symptoms are usually not obvious. The main preventive measures are the same as those for intimal injury and stripping of the hepatic artery.

　　3, Liver artery puncture and pseudo-aneurysm formation

　　The incidence rate is 0.17% to 0.35%. High-risk factors:

　　(1) Same as 'intimal injury and stripping of the hepatic artery'.

　　(2) Failure of the high-pressure injector to inject pressure, especially when the end hole of the catheter is tightly attached to the arterial wall.

　　Clinical manifestations: There are usually no obvious clinical symptoms; if the large artery branch is pierced, abdominal pain, hemorrhagic shock, and other symptoms may occur. Diagnosis is not very difficult. The main preventive measures are the same as mentioned above.

　　4, Multiple hepatic intrapulmonary aneurysms

　　The incidence rate is 0.26% to 0.38%. The cause is controversial, and most scholars believe it is related to the following reasons

　　(1) Stimulation from guide wires, catheters, chemotherapy drugs, and embolic agents;

　　(2) Inflammation and increased fragility of the vascular wall after embolization of the blood supply branch; most have no clinical symptoms.

　　Prevention: Try to use microcatheters and superselective catheterization. This phenomenon usually disappears within 3 to 12 months after THACE surgery.

　　Four, Complications of the Liver and Bile Duct System

　　1, Acute liver failure

　　Most patients with primary liver cancer are accompanied by liver cirrhosis and liver dysfunction, and the chemotherapy drugs used in THACE not only have a great killing effect on liver cancer cells but also damage normal liver cells. If the perfusion dose is too large or / and non-selective catheter over-chemotherapy embolization, it will cause serious damage to normal liver tissue and lead to acute liver failure. In addition, it is also the final outcome of other serious complications after THACE.

　　The incidence rate is 0.3% to 1% (by case). High-risk factors include:

　　(1) Those with poor liver reserve function before interventional surgery, such as Child B, C grade or Okuda II, III grade, lactate dehydrogenase greater than 425U/L, aspartate aminotransferase >100mL, serum bilirubin >2mg/dL, liver tumor >50%.

　　(2) Those with main portal vein or primary branch cancer thrombus.

　　(3) Those with significant portal hypertension caused by liver cirrhosis or / and portal vein cancer thrombus.

　　(4) Those with large tumors and without superselective catheter injection of hyperosmotic iodized oil suspension chemotherapy drugs.

　　Clinically, rapid deepening of jaundice, persistent nausea and vomiting, liver odor, significant reduction in liver dullness, toxic megacolon, ascites, and bleeding of the skin and mucous membranes can occur quickly; followed by acute renal insufficiency (hepatorenal syndrome) and varying degrees of hepatic encephalopathy leading to coma. Most patients die within a few days due to liver and kidney failure or severe bleeding.

　　The prognosis of such complications is extremely poor, with a mortality rate of up to 50% to 90%.

　　2, Liver infarction (necrosis)

　　The injection of a large amount of iodized oil suspension chemotherapy drug (or reflux into) the normal liver tissue supplying the hepatic artery branches around the tumor can cause ischemia of the liver tissue in the supplying area, which may lead to infarction (necrosis) of the liver tissue. The incidence rate is 0.1% to 0.2% (by case). High-risk factors include:

　　(1) Those with main portal vein obstruction (tumor invasion or cancer thrombus).

　　(2) Those with significant hepatic artery-pulmonary vein shunting (APVS).

　　(3) Those who have not performed superselective catheter injection of hyperosmotic iodized oil suspension chemotherapy drugs.

　　(4) Those who have applied liquid embolic agents (such as anhydrous alcohol) or small diameter (50μm) particle embolic agents. Clinical manifestations include upper right abdominal pain, jaundice, fever (especially in secondary infections), liver function damage, or acute liver failure. CT and MRI scans can clearly show the range, degree, and nature (hemorrhagic or non-hemorrhagic infarction) of liver infarction after THACE, as well as the local liver atrophy caused by it.

　　Most cases are in the middle-aged and elderly, with acute onset, sudden severe upper right abdominal pain, profuse sweating, pale complexion, rapid and thin pulse, decreased blood pressure, tenderness and percussion pain in the liver area, muscle tension, rapid deepening of jaundice with fever, significant liver function damage, acute prolongation of prothrombin time, which cannot be restored by non-vitamin K treatment, and most are accompanied by intestinal paralysis, oliguria, shock, and coma, and die quickly. If the patient survives the acute phase, attention should be paid to the changes in organ function of various systems and the corresponding symptoms and signs that appear, such as splenomegaly, pancreatic swelling, ischemic manifestations of the intestines, oliguria caused by renal ischemia, anuria, or uremia, and so on.

　　Methods to prevent hepatic artery occlusion:It is necessary to change bad living habits, quit smoking, avoid high-fat, indigestible, and irritant foods, eat light, eat more fruits and vegetables, beans, and other foods. Patients with hypertension, hyperlipidemia, and diabetes should actively treat the primary disease. Strictly monitor the condition and do not take it lightly. Obese patients should lose weight and exercise appropriately to increase collateral circulation, but should not move heavy objects.

　　1. Blood count:White blood cell count increased.

　　2. Liver function test:Alanine aminotransferase, aspartate aminotransferase significantly increased.

　　3. Prothrombin:The time is significantly prolonged, which cannot be restored by vitamin K.

　　4. Doppler ultrasound examination:It can be seen that the blood flow of the hepatic artery is interrupted, and there may be collateral compensation, but it is rare. There may be liquefaction foci in the liver parenchyma, and CT can show concentrated or scattered hypodense areas in the liver parenchyma. Abdominal aortic angiography is of great significance for diagnosis, showing a cutoff or conical sign in the hepatic artery, and there may be collateral formation around it.

　　First, food therapy recipes:

　　1. Garlic Porridge:Glutinous rice 100 grams, purple skin garlic 30 grams. Peel the garlic, put it in boiling water for 1 minute, then remove it. Boil the glutinous rice in the garlic water to make thin porridge, then add the garlic again, and cook together to make porridge. Eat in the evening. This recipe has the effect of warming yang, activating blood circulation, and removing blood stasis, used for yang deficiency and cold congealment, and blood stasis blocking meridians. Caution should be exercised with blood stasis and heat obstruction.

　　2. Hawthorn and Pear Paste:Fatty hawthorn and sweet pear each 10 kilograms. Remove the seeds, pound and extract the juice, boil in a pot, add 120 grams of refined honey to make paste. Take as needed.

　　3. Red Bean Porridge:Appropriate amount of red bean, soak for half a day, cook with 100 grams of glutinous rice to make porridge. Take once a day.

　　4. Radish Porridge:Fresh radish 250 grams, glutinous rice 100 grams. Cut the radish into pieces and cook with the glutinous rice to make porridge. Take once a day.

　　5. Black and Wolfberry Soup:Polygonum multiflorum, Fructus Lycii, and Rhus chinensis each 30 grams. Boil the water to 300 milliliters each day, take twice a day, one dose each day.

　　6. Ginseng and Silver Ear Soup:Ginseng 5 grams, silver ear 10 to 15 grams. Soak the silver ear in warm water for 12 hours first, wash it. Cut the ginseng into thin slices and simmer over low heat for 2 hours, then add the silver ear and boil for another hour. Take twice a day, in the morning and evening.

　　7. Almond Rice:Bitter almonds 10 grams, glutinous rice 50 to 100 grams. Boil the bitter almonds, peel and take the juice, boil the glutinous rice together with the juice. Take once a day. This recipe has the effect of activating blood circulation and removing blood stasis, used for blood stasis blocking meridians.

　　8. Double Ears Soup:Black fungus and white fungus, each 10 grams, red dates, 15 pieces. Soak and wash in warm water, put into a bowl, add water and a small amount of rock sugar, steam for 1 hour, serve with the soup, twice a day. This recipe has the effect of cooling blood and activating blood circulation, used for blood stasis blocking meridians, and blood stasis and heat obstruction.

　　9. Baozhao:Allium fistulosum 10-15 grams, scallion 2 stems, white flour 100-150 grams. Mix well and boil in boiling water. Take in two doses. This recipe has the effect of warming the kidney and Yang, and is used for those with insufficient kidney Yang. Caution should be exercised for those with blood stasis and heat obstruction.

　　2. Suitable Foods:Fresh vegetables, fruits, lean meat, eggs, milk, and various bean products, high sugar, high protein, high vitamin foods such as winter melon, melon, glutinous rice, mung beans, cucumber, crucian carp, and eat more fiber-rich foods such as celery, spinach, and bananas.

　　3. Unsuitable Foods:Greasy, fried foods, spicy and stimulating foods. Nourishing foods. Nourishing foods.

　　1. Treatment

　　The treatment principle is anti-shock, sedation, analgesia, antispasmodic, anticoagulation, oxygen supply, and antibiotic application, while liver protection therapy is also provided. Low molecular weight dextran can improve the microcirculation of internal organs, and plasma and its substitutes can alleviate shock. Those who have the conditions should be sent to the ICU for sufficient oxygen supply or artificial respiration, with the assistance of an anesthesiologist, while antispasmodic, analgesic, and intravenous rapid fluid replacement are also provided to help the patient through the shock and vascular spasm phase, expecting the compensation of collateral circulation, while further investigating the cause and location of the disease to make further treatment, such as thrombectomy and thrombolysis.

　　Integrated traditional Chinese and Western medicine treatment: There have been no reports of integrated traditional Chinese and Western medicine treatment for this disease in China, but the application of traditional Chinese medicine in the treatment of emergency cases in the department of hepatology is a field worth exploring. According to the characteristics of this disease,活血化瘀 and supplemented with acrid, warm, and permeating herbs such as musk and scallion, combined with high-dose antibiotics, has a good therapeutic effect on rapid improvement of symptoms.

　　2. Prognosis

　　The prognosis of this disease depends on the location of the blockage and the formation of collateral circulation. If the blockage is located near the origin of the stomach, duodenal artery, and right gastric artery, there is usually sufficient collateral circulation to maintain life; if the blockage is located at the distal end of the origin of these arteries, the consequences vary with the type of artery. There have been reports of death due to accidental ligation of the hepatic artery during surgery, but there have also been cases of recovery. Patients who continue to survive may be due to the formation of good collateral circulation of the diaphragmatic artery or subcapsular artery of the liver, or because the main artery has not been cut. The prognosis of slowly forming thrombi is better than that of sudden blockage.