Unexpected hepatic lymphangiography during transcatheter arterial chemoembolization in a patient with hepatocellular carcinoma: a case report

Visualization of hepatic lymphatic vessels during transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) is uncommon. A woman in her 70s with alcoholic liver cirrhosis and type 2 diabetes mellitus underwent TACE for recurrent HCC in segment 6 after treatment for cholangitis. The procedure was performed via the left distal radial artery using a 5-F angiographic catheter and a 1.9-F microcatheter. During Lipiodol injection into the tumor-feeding artery, abnormal opacification extending toward the hepatic hilum was observed, raising suspicion for arterio-lymphatic communication; therefore, the procedure was discontinued, although the patient remained asymptomatic. Follow-up computed tomography performed 1 month later revealed Lipiodol accumulation within the hepatic lymphatic vessels and in the abdominal, mediastinal, and supraclavicular lymph nodes, with no adverse clinical events during follow-up. Repeat TACE performed 6 months later for the same HCC showed no lymphatic opacification, suggesting that the previous finding represented a transient arterio-lymphatic communication, possibly related to intrahepatic lymphatic dilatation associated with liver cirrhosis and tissue injury caused by cholangitis. Recognition of this phenomenon is important for interventional radiologists to appropriately interpret intraprocedural findings and guide procedural decision-making during TACE.