INTRODUCTION: Hepatocellular Carcinoma, HCC, has a median survival of 6 to 20 months and a 5-year survival of 10%. Liver transplantation (LT) offers the best results in terms of overall survival (OS) and disease-free survival (DFS), but patients must fall into the Milan criteria for transplant. Locoregional therapies such as drug eluting bead transarterial chemoembolization (DEB-TACE), conventional transarterial chemoembolization (cTACE), Y-90 radioembolization, microwave ablation (MWA), and radiofrequency ablation (RFA) severe as a bridge to maintain patients within the Milan criteria in order to be able to proceed with LT. We aimed to compare the efficacy of different interventional radiology (IR) liver directed therapies for hepatocellular carcinoma (HCC) in pre-liver transplant patients at our institution. METHODS: We retrospectively reviewed patients at CCF who have received DEB-TACE, cTACE, Y-90, RFA, MWA, or multi-modal therapy (MMT) as a bridge to LT from 2014-2019. We analyzed pathologic response of the HCC tumor in the explanted organ and rate of failure after bridge therapy. We calculated DFS and overall 5-year survival after LT. RESULTS: 65 patients with a mean age of 65.3 years of age (range of 42-75) met inclusion criteria. 35 patients (53.8%) had HCV cirrhosis, 14 (21.5%) NASH cirrhosis, 6 (9.2%) alcoholic cirrhosis, 3 (4.6%). Patients received a total of 97 procedures: DEB-TACE (n = 44), cTACE (n = 5), Y-90 (n = 8), RFA (n = 4), MWA (n = 1), MMT (n = 35). Transplant occurred at a mean of 48.1 weeks after bridge therapy. Pathological response among 97 lesions was 100% necrosis (n = 33, 34%), >50% necrosis (n = 29, 29.9%), < 50% necrosis (n = 13, 13.4%), and no necrosis (n = 22, 22.7%). Pathologic complete (100%) response was as follows: Complete, 100% tumor response was seen in 22.7% (10/44) of DEB-TACE, 20% (1/5) of cTACE, 12.5% (1/8) of Y-90, 50% of RFA (2/4), 100% of MWA (1/1), 51.4% of MMT. MMT was significantly more likely to achieve complete pathologic remission than DEB-TACE (P < 0.01) and Y-90 (P = 0.048) alone. At a median follow-up of 31 months, 3 patients had recurrence after LT. Disease free survival (DFS) was 92.5% and overall survival was 77.5% at 5 years. CONCLUSION: All IR liver directed therapies demonstrated good pathological response and disease free survival after LT. MMT was the most effective in achieving complete pathological remission. Further evaluation can be done on which combinations of IR liver directed therapy in multimodal therapy provide greatest necrosis.Figure 1.: A breakdown of the 97 procedures performed.Figure 2.: The percent of each modality achieving complete pathologic necrosis.Figure 3.: A comparison of the 5 year survival of DEB-TACE vs. Multi-modal Therapy.