Reply: To PMID 25045002.

Abstract

TO THE EDITORS: We thank Panaro et al. for their interest and comments regarding our study on hepatic artery (HA) and biliary complications in liver transplantation (LT) recipients treated with transarterial chemoembolization (TACE). Panaro et al.1 reported their findings on the histologic and radiologic effects of TACE on the HA in 67 patients with hepatocellular carcinoma (HCC). The incidences of histologic and radiologic HA abnormalities in 32 patients treated with TACE were 100% and 22%, respectively. This is compared to 22% and 8%, respectively, in 37 patients not treated with TACE. In our study, we report a 7.9% HA complication rate in patients treated with TACE and a 4.7% rate in the no‐TACE group.2 However, all HA stenosis events occurred in patients who had undergone TACE (P = 0.018 versus the no‐TACE group). There are several important distinctions to note between these studies. First, only complications requiring a therapeutic intervention were included in our study. This likely explains the higher percentage of HA complications found by Panaro et al.1 in comparison with other published findings, including the 13% HA complication rate reported by Richard et al.3 Second, Panaro et al. performed very frequent radiologic assessments after LT to evaluate the HA. This is not the standard of care and is likely to detect more abnormalities than would otherwise be seen in routine clinical practice. Third, the median follow‐up time in our study was 4.01 years, whereas it was 1.42 years in the study by Panaro et al. Our median time from LT to HA complication was 27 days (interquartile range = 3‐688 days), but complications were detected as far out as 5 years. Finally, we acknowledge the study from Lin et al.,4 who reported an increased incidence of HA intimal dissection in 40 living donor LT recipients treated with TACE versus 14 without TACE. Unfortunately, we are unable to comment on the prevalence of intimal dissection in our study. In summary, the study by Panaro et al. provides insight into the underlying mechanisms of arterial wall injury induced by TACE,5 and our findings provide the clinical correlation to these histologic findings. The limitations of a retrospective study design, used in our study and that of Panaro et al, are well‐recognized. However, the inclusion of 2 centers in our study improves the generalizability; the findings at each independent center are consistent with our overall findings. As reported in Table 2,2 we did not find a significant association between the number of TACE procedures and the median number of days between last TACE and LT with respect to post‐LT HA complications. Collectively, these results highlight the histologic and clinical effects of TACE on the HA in patients with HCC. However, the magnitude of this effect on post‐LT survival or graft survival has not been demonstrated. Because of the rising prevalence of HCC and increasing LT wait times, additional prospective studies are warranted to further characterize the association between TACE and HA injury before decision‐making strategies for patients with HCC are altered.