Quantitative assessment of angiographic perfusion reduction using color-coded digital subtraction angiography during transarterial chemoembolization

The aim of this study was to develop a quantitative measurement of perfusion reduction using color-coded digital subtraction angiography (ccDSA) to monitor intra-procedural arterial stasis during TACE.

A total number of 35 patients with hepatocellular carcinoma who had undergone TACE were enrolled into the study. Pre- and post-two-dimensional digital subtraction angiography scans were conducted with same protocol and post-processed with ccDSA prototype software. Time-contrast-intensity (CI[t]) curve was obtained by region-of-interest (ROI) measurement on the generated ccDSA image. Quantitative 2D perfusion parameters time to peak, area under the curve (AUC), maximum upslope, and contrast intensity peak (CI-Peak) derived from the ROI-based CI[t] curve for pre- and post-TACE were evaluated to assess the reduction of antegrade blood flow and tumor blush. Relationships between 2D perfusion parameters, subjective angiographic chemoembolization endpoint (SACE) scale, and clinical outcomes were analyzed.

Area normalized AUC and CI-Peak revealed significant reduction after the TACE (P < 0.0001). AUC_norm decreased from pre-procedure of 0.867 ± 0.242 to 0.421 ± 0.171 (P < 0.001) after completion of TACE. CI-Peak_norm was 0.739 ± 0.221 before TACE and 0.421 ± 0.174 (P < 0.001) after TACE. Tumor blood supply time slowed down obviously after embolization. A perfusion reduction either from AUC_norm or CI-Peak_norm ranging from 30% to 40% was associated with SACE level III and a reduction ranging from 60% to 70% was equivalent to SACE level IV. For intermediate reduction (SACE level III), better tumor response was found after TACE rather than a higher reduction (SACE level IV).

ccDSA application provides an objective approach to quantify the perfusion reduction and subjectively evaluate the arterial stasis of antegrade blood flow and tumor blush caused by TACE.