Hepatobiliary and Pancreatic: Diaphragmatic paralysis after transarterial chemoembolization of hepatocellular carcinoma

Abstract

A 60-year-old male underwent transarterial chemoembolization (TACE) to treat hepatocellular carcinoma (HCC) on a background of Child–Pugh A cirrhosis from previous hepatitis C infection and alcohol excess. The procedure targeted a 30-mm segment 8 HCC (Fig. 1a, arrowheads), adjacent to the right inferior phrenic artery (IPA) (Fig. 1a, arrow). Angiography showed the lesion was supplied by the right IPA (Fig. 1b, arrow) and the posterior branch of the right hepatic artery. It was treated with conventional TACE using lipiodol and cisplatin via both feeding arteries on two occasions 5 months apart. One month after the second TACE, he developed new onset exertional dyspnea (difficulty walking up 10 stairs), and a reduction in exercise tolerance to 500 m. Subsequent CT scans to monitor HCC treatment response demonstrated elevation of the right hemidiaphragm. A fluoroscopic sniff test confirmed paradoxical movement of the right hemidiaphragm, consistent with paralysis (Fig. 2). The patient was worked up for and eventually received a liver transplant. The right IPA (arising from the IPA) is the most common extrahepatic artery to supply HCCs. The IPA supplies most of the diaphragm along its undersurface. Chemoembolization of IPA can cause diaphragmatic ischemia and weakness as shown on pulmonary function tests in up to 40% of patients. However, few patients become symptomatic as seen in this case.