Hepatobiliary Interventional Radiology

Hepatobiliary interventional radiology treats liver cancer, portal hypertension and liver transplant complications through a needle or a catheter, guided by ultrasound, CT, MRI and fluoroscopy. Dr. Shobhit Singh, Consultant - Intervention Radiologist - Gastroenterology & Hepatology, BLK-Max Super Speciality Hospital, New Delhi, India, works within the hospital, where most of his work supports liver transplant and digestive disease teams.

His starting point is that the specialty is still under-recognised. Interventional radiology has not yet made inroads into every part of the world, and even in India many people do not know what it can offer. This guide sets out what the field now does in the liver and gut, how liver cancer is staged and matched to treatment, how interventional radiology keeps transplant candidates eligible, and what international patients need to know about how a liver for transplant is obtained. The deeper articles in the series cover liver tumour ablation, TACE and TARE, and portal hypertension, transjugular procedures and post-transplant rescue.

How interventional radiology grew from diagnosis into treatment

Radiology began as a diagnostic discipline. It has since become a procedure-based specialty, practised in a cath lab suite where the patient is taken for treatment rather than only for a scan. Dr. Singh traces that shift through three eras.

• The early diagnostic era (before the 1970s). Imaging meant plain X-ray and, in some centres, ultrasound. Only a handful of percutaneous procedures, such as drainage, were possible.
• The 1970s to the 1990s. Widespread ultrasound made image-guided drainage and therapeutic vascular access routine.
• 2000 to the present. Multi-slice CT, MRI and cone-beam CT (a CT image acquired in the procedure room by a rotating C-arm) turned interventional radiology into what he calls a sister branch of gastroenterology and hepatobiliary science, one that helps colleagues manage the complex cases they meet in day-to-day practice.

What hepatobiliary interventional radiology covers

The range of procedures is wider than most referring doctors assume. Dr. Singh groups it into four families.

Hepatobiliary oncology. Primary liver cancer, hepatocellular carcinoma (HCC), is treated with radiofrequency ablation, microwave ablation and cryoablation, and with transarterial therapies: transarterial chemoembolisation (TACE), radioembolisation (TARE) and bland embolisation of the vessels feeding the tumour. Portal vein embolisation is done before liver surgery: blocking the portal supply to the part of the liver that will be removed makes the remaining liver grow, so surgeons can operate safely.

Vascular intervention. This includes managing portal hypertension with a transjugular intrahepatic portosystemic shunt (TIPS); reopening a blocked hepatic vein or inferior vena cava (IVC) in Budd-Chiari syndrome; and stopping acute bleeding, including bleeding from a pseudoaneurysm after surgery.

Biliary intervention. Percutaneous transhepatic biliary drainage (PTBD), biliary stenting, percutaneous cholecystostomy (draining the gallbladder through the skin) and stone management. Dr. Singh deliberately left biliary work out of the session because it is a long topic of its own.

Transjugular and transplant work. Liver biopsies can be taken and portal pressure measured through the jugular vein even in patients who bleed easily, and vascular complications after liver transplant can be treated by catheter without reopening the abdomen.

What links these procedures, in his words, is that they are selective and super-selective interventions rather than basic ones, offered mainly to transplant and gastroenterology patients.

Interventional radiology for liver cancer (HCC): the scale of the problem

Hepatocellular carcinoma is the main indication for hepatobiliary interventional radiology. Dr. Singh put its incidence at around 800,000 new cases a year, with a five-year survival of about 20%.

The causes differ by region. In the western world, alcohol-related liver disease and hepatitis C are major causes, and a fast-growing share arises from metabolic dysfunction-associated steatotic liver disease (MASLD, formerly non-alcoholic fatty liver disease), whose inflammatory form, once called NASH, is now termed MASH. In India, Southeast Asia and Africa, infection remains a major cause of cirrhosis, chiefly hepatitis B and hepatitis C, along with drug-induced liver injury over time and other factors. HCC therefore usually arises in a liver that is already damaged, which shapes every treatment decision.

Treatment is multi-modality: surgical resection and liver transplant; locoregional therapy (ablation and transarterial therapy) when a patient is not a transplant candidate or needs time before transplant; and systemic chemotherapy and, increasingly, immunotherapy when the disease has spread or no other option is possible. The interventional radiologist's role lies in the locoregional space.

The four variables that decide HCC treatment

Four variables decide which treatment a patient with HCC can receive:

1. Tumour burden: how many tumours are in the liver and how large they are.
2. Vascular involvement: whether the tumour has invaded the portal vein or a hepatic vein.
3. Liver function: the bilirubin, the platelet count and the INR (a measure of blood clotting), which together show whether the liver is still working normally.
4. Performance status: whether the patient can look after themselves independently, or is bedridden because of ascites (fluid in the abdomen) or protein loss.

BCLC staging

These variables feed into the Barcelona Clinic Liver Cancer (BCLC) staging system, which sorts HCC into five stages: very early, early, intermediate, advanced and terminal. BCLC classifies patients by tumour burden, liver function and performance status, and links each stage to a recommended treatment and an expected survival.

HCC treatment by stage

Very early and early stage. In BCLC terms, very early disease is a single tumour of 2 cm or less, and early disease is a single tumour or up to three nodules each no larger than 3 cm. Options are surgical resection, liver transplant, or ablation by radiofrequency, microwave or chemical (alcohol) injection. Dr. Singh put expected survival after these treatments at more than five years, and resection or transplant can be curative.

Intermediate stage. Here locoregional therapy takes centre stage: TACE (TACE cost guide), TARE, stereotactic body radiotherapy (SBRT, precisely targeted high-dose radiotherapy) and combinations of them. Dr. Singh's view is that good survival, beyond two years, is still achievable at this stage.

Advanced stage. Once the disease has spread, systemic therapy is the treatment. Surgery and locoregional therapy are no longer offered, and expected survival falls.

Terminal stage. Best supportive care is the need. Expected survival is under three months, and the aim is not to prolong treatment but to keep the remaining time peaceful and complications few.

Ablation can cure many small tumours outright. Transarterial therapy controls larger ones. Both also serve a third purpose that matters greatly to international patients: keeping a transplant candidate eligible while the transplant is arranged.

Bridge to transplant: keeping liver cancer patients eligible

A patient with HCC may be a good transplant candidate but have no donor yet. The family may still be looking for a suitable donor or arranging finances, and that can take months. If nothing is done in that time, the tumour grows and may spread outside the liver, and the window for transplant closes.

Locoregional therapy keeps it open. Dr. Singh's practice is to treat the tumour with ablation, TACE or TARE during the wait, so that when the donor is available the disease has not progressed and the transplant can go ahead. This is the bridge to transplant. Left untreated for six months, he said, the tumour grows and can spread beyond the liver; with locoregional therapy, the family can take four or five months to arrange the transplant without the tumour growing, and the patient remains within the time frame for a successful transplant or operation.

Downstaging with AFP

Transplant and surgery cannot be offered to every patient with liver cancer; there are criteria. One marker is alpha-fetoprotein (AFP), a blood protein that rises in HCC. Dr. Singh noted that AFP is normally under 7 to 10 ng/mL, and that patients whose AFP runs into the thousands, 10,000 or 20,000, cannot have surgery or a transplant.

In selected patients, he offers TACE or TARE. Dr. Singh described AFP falling below 1,000 within one to two months of treatment, bringing the patient back within transplant criteria. Bringing a patient into criteria, he said, is one of the jobs of the interventional radiologist. Transplant eligibility thresholds for AFP vary between programmes and countries, so the target in an individual case is set by the transplant team; for liver resection, AFP informs prognosis rather than setting a fixed cut-off.

What locoregional therapy can and cannot do for a cirrhotic liver

Ablation and transarterial therapy treat the tumour, not the cirrhosis. Dr. Singh was explicit on this point: the cirrhotic liver is managed by the transplant team, hepatologists and gastroenterologists. The interventional radiologist's aim is to stop the tumour progressing, kill it, and watch that no new tumour forms in the cirrhotic liver.

After these procedures, liver function tests may deteriorate slightly for one to two days and then improve over time. They will not return to normal, because the liver remains cirrhotic. The true treatment for a cirrhotic liver is transplant, which replaces the diseased organ and solves most of the problem. Transplant cannot be offered to every patient, and locoregional therapy serves those who are not candidates and those who need time.

Liver transplant donor rules for international patients

For international patients, the source of the donor liver is often the deciding question. Under Indian law there are two sources. The first is a deceased (cadaveric) donor, whose family consents to organ donation. The second is a living donor, who gives part of their liver.

For a foreign national, only a related living donor is eligible: a relative by blood, cousins included, or a spouse. The hospital's Authorisation Committee approves each donation after verifying the relationship through stringent documentation, and genetic testing is commonly used to confirm a blood relationship.

Deceased-donor livers are allocated to Indian citizens. A foreign national can receive one only in the rare situation where no Indian recipient is a match, so that the organ is not wasted. In practice, an international patient needs a living donor who is a blood relative or spouse, and should plan around that from the first consultation. Jivo Healthcare's liver transplant cost guide covers the costs, and the liver cancer surgery (hepatectomy) cost guide covers resection. Transplant surgeons are listed under hepatobiliary and liver transplant surgery.

Xenotransplantation: an evolving field

Asked about transplanting pig livers into humans, Dr. Singh said he had read of a case in which the patient survived for a few days. Xenotransplantation lies outside his field, and his assessment was limited: transplantation across species is still evolving, and research continues.

Where to go next

The procedures summarised here are covered in depth in the rest of the series:

• Liver tumour ablation compared: alcohol, radiofrequency, microwave and cryoablation, including irreversible electroporation, histotripsy and the techniques that protect nearby organs.
• TACE and TARE for liver cancer: patient selection, conventional, drug-eluting bead and balloon-occluded TACE, radioembolisation and combination therapy.
• Portal hypertension and transplant rescue: transjugular liver biopsy, HVPG measurement, Budd-Chiari syndrome, BRTO and PARTO, TIPS, and vascular complications after liver transplant.

The audience's questions and Dr. Singh's answers are on the live discussion page. Related specialists are listed under interventional radiology.