2336 Multiple Uncommon Complications After TACE

Abstract

INTRODUCTION: TransarteriaL chemoembolization (TACE) is a widely-used treatment for unresectable hepatocellular cancer (HCC). Although TACE is minimally invasive, major complications occur in 5% of cases. These include acute cholecystitis, which is self-limiting and rarely requires surgical intervention. Liver abscess is a rare complication but can increase length-of-stay and morbidity. Our case focuses on multiple uncommon complications of TACE occurring in conjunction; gangrenous cholecystitis requiring emergent cholecystectomy, liver abscess and portal vein thrombosis. CASE DESCRIPTION/METHODS: A 67-year-old male with history of hepatitis C, cirrhosis and HCC status-post recent successful TACE who presented to the ER with right upper quadrant pain associated with fever. Physical examination with right upper quadrant tenderness and positive murphy’s sign. Laboratories showed leukocytosis and elevated alkaline phosphatase. Normal bilirubin, liver and pancreatic enzymes. Abdominopelvic CT with hydropic gallbladder with enhancing walls and pericholecystic inflammatory changes, new ill-defined hypodensities suggestive of abscess and extensive thrombus in the right portal vein. The patient received antibiotics and underwent an uneventful cholecystectomy. Post-operation findings consistent with a gangrenous gallbladder with severe adherent hepatic flexure and omentum to the gallbladder fundus. The patient was discharged on antibiotics and anticoagulation. Follow up MRI showed resolution of fluid filled lesions with almost complete resolution of the portal vein thrombosis. DISCUSSION: Cholecystitis is a complication of TACE due to reflux of the embolic material into the cystic artery. In most cases, management can be conservative. Our case is rare given that the patient developed gangrenous cholecystitis which is a serious complication that requires immediate surgical intervention. Liver abscess occurs infrequently unless there is a history of prior biliary reconstruction unlike our patient. Management includes antibiotics and percutaneous drainage for larger abscesses. In our case, our patient responded well to antibiotics. Because symptoms are non-specific, these complications may be mistaken for post embolization syndrome, which is usually self-limiting and abates by one week. Normal post-TACE CT findings can also confound the diagnosis of hepatic abscess formation. This case highlights the importance of being aware of complications of TACE as failure to recognize these may confer a higher mortality risk.