Selective Angiographic Roadmap Analysis (SARA) of Hepatocellular Carcinoma Feeding Arteries for Transarterial Chemoembolization

TL;DR

This paper introduces SARA, a systematic method for identifying tumor blood vessels in liver cancer to improve treatment outcomes.

Contribution

The novel contribution is the SARA framework, a standardized roadmap for angiographic planning in HCC treatments.

Findings

SARA improves identification of tumor feeders and reduces nontarget embolization.

Incorporating CBCT and advanced imaging enhances arterial mapping accuracy.

SARA principles apply to both TACE and TARE, improving treatment precision.

Abstract

Hepatocellular carcinoma (HCC) is a hypervascular malignancy commonly treated with transarterial chemoembolization (TACE), in which success relies on the accurate identification and embolization of tumor feeding arteries while sparing the nontumorous liver parenchyma. This review introduces the concept of selective angiographic roadmap analysis (SARA), a systematic and stepwise approach to evaluating hepatic arterial supply in HCC, with the aim of standardizing angiographic planning and improving TACE outcomes. SARA emphasizes recognition of typical and variant hepatic arterial anatomy, systematic identification of accessory and extrahepatic feeders, and integration with intraprocedural cone-beam computed tomography (CBCT) to enhance feeder detection and reduce nontarget embolization. Although primarily applied in TACE, the principles of SARA are equally relevant to transarterial radioembolization (TARE) where precise arterial mapping is critical. Embolization strategies are discussed across different levels of selectivity, from lobar to superselective techniques. The complementary role of advanced imaging modalities, such as CT angiography (CTA), MR angiography (MRA), and artificial intelligence-assisted vessel tracking, is also explored. Adopting the SARA framework in conjunction with these technologies may improve technical success and tumor control and preserve liver function in patients undergoing intra-arterial therapies.

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