About Dr. Wang Jianhua
Dr. Wang Jianhua is Chief of Interventional Radiology at Zhongshan Hospital, Fudan University — one of China's foremost academic centres for minimally invasive oncological intervention. He specialises in transarterial chemoembolisation (TACE), tumour embolisation, and complex vascular interventional procedures, with particular expertise in technically demanding cases involving arterioportal shunts, portal vein tumour thrombus, and advanced hepatocellular carcinoma. Dr. Wang's practice is defined by the philosophy that interventional radiology is not a palliative adjunct to oncological care — it is a primary, potentially curative treatment modality for patients who cannot be served by surgery or systemic therapy alone. His team at Zhongshan Hospital has pioneered the combined hepatic artery and portal vein dual-intervention strategy for HCC with portal vein tumour thrombus, converting cases previously considered untreatable into controlled chronic disease with meaningful survival extension.
Case Overview
Mr. Robert Chen, a 58-year-old retired teacher with a 15-year history of hepatitis B cirrhosis and no regular antiviral therapy, presented with one month of right upper quadrant distension and fatigue, and a three-day history of newly diagnosed hepatocellular carcinoma. AFP exceeded 1,210 ng/mL. Contrast-enhanced CT confirmed a 12 cm × 10 cm right hepatic HCC with arterial enhancement and washout, Vp3 portal vein tumour thrombus (PVTT) occluding the right portal branch and main trunk, and a high-flow arterioportal shunt (AP shunt) — a combination that rendered the patient ineligible for surgical resection (Child-Pugh B, BCLC Stage C) and conventionally contraindicated for standard TACE. Dr. Wang Jianhua designed a staged precision intervention: microcatheter superselective cannulation of the tumour-feeding arteries, micro-coil occlusion of the AP shunt, drug-eluting bead TACE (DEB-TACE) with epirubicin-loaded CalliSpheres microspheres, followed two weeks later by percutaneous transhepatic portal vein stenting and iodine-125 seed strand brachytherapy for the tumour thrombus. AFP fell from 1,210 to 150 ng/mL at one month. Tumour volume reduced by 30%. Portal vein flow was restored. The patient was subsequently commenced on lenvatinib plus PD-1 immunotherapy. At 18 months, he remains alive with controlled disease and ECOG performance status 1.
Patient Background
- Name / Nationality: Mr. Robert Chen (pseudonym) — retired teacher
- Age / Sex: 58-year-old male
- Chief Complaint: Right upper quadrant distension and fatigue for 1 month; HCC diagnosed 3 days prior
- Hepatic History: Hepatitis B cirrhosis for 15 years; no regular antiviral therapy; HBV-DNA 1.0 × 10⁵ copies/mL
- Examination: Liver palpable 4 fingerbreadths below costal margin; firm; nodular surface; mild tenderness; no ascites
- Liver Function: Child-Pugh B (score 7); albumin 32 g/L; bilirubin 28 μmol/L; prothrombin time prolonged 3 seconds
- Tumour Markers: AFP >1,210 ng/mL; PIVKA-II 800 mAU/mL
- Clinical Stage: BCLC Stage C (advanced); not eligible for surgical resection
Imaging Assessment
Contrast-Enhanced CT / MRI
- Primary tumour: Right hepatic lobe mass 12 cm × 10 cm; arterial phase hyperenhancement with portal phase washout — diagnostic of HCC
- Portal vein tumour thrombus (PVTT): Filling defect in right portal branch and main portal trunk — Vp3 classification; the primary driver of portal hypertension and hepatic decompensation risk
- Arterioportal shunt (AP shunt): Direct communication between hepatic arterial branches and portal venous branches on DSA — early portal venous opacification confirming high-flow shunt; this is the critical anatomical hazard that makes standard TACE dangerous
- Collateral circulation: Extensive extrahepatic collateral vessels
Why Standard TACE Was Contraindicated
Two anatomical findings created absolute contraindications to conventional TACE: the Vp3 PVTT occluding the main portal trunk — meaning the liver's dual blood supply was already compromised, and hepatic artery embolisation risked precipitating acute liver failure; and the high-flow AP shunt — meaning conventional embolic agents (lipiodol, gelatin sponge) would pass through the shunt into the portal circulation, causing pulmonary embolism, intestinal ischaemia, and failure to accumulate within the tumour. Standard TACE in this anatomical configuration is not merely ineffective. It is potentially fatal.
Clinical Decision Making
The patient occupied the most technically challenging position in HCC management: inoperable due to liver function reserve, ineligible for standard TACE due to PVTT and AP shunt, and with disease too advanced for ablation alone. Untreated, median survival in this configuration is below three months.
Dr. Wang Jianhua's precision intervention strategy: This patient has three problems that must be solved in sequence. The AP shunt is the first problem — it is the anatomical trap that makes any arterial intervention dangerous. We must close the shunt before we embolise the tumour, or the embolic material will escape into the portal circulation. The PVTT is the second problem — it is blocking the portal vein and slowly destroying the liver's functional reserve. We must restore portal flow or the liver will fail regardless of what we do to the tumour. The tumour itself is the third problem — and it becomes addressable only after the first two are solved. Sequence is everything in complex interventional oncology.
Interventional Procedure
Phase 1 — Diagnostic Angiography and AP Shunt Occlusion
Access: Right femoral artery puncture (Seldinger technique); 5F arterial sheath placed.
DSA angiography: Confirmed high-flow arterioportal shunt between right hepatic artery branches and right portal vein — early portal venous opacification within 2 seconds of arterial injection. Tumour vascularity mapped: multiple feeding arteries from right hepatic artery branches.
AP shunt occlusion: 2.7F microcatheter (Renegade) advanced superselectively to the shunt origin. Micro-coils deployed at the shunt entry point — creating a mechanical barrier that prevents embolic material from entering the portal circulation during subsequent tumour embolisation. Repeat angiography confirmed shunt flow eliminated before proceeding.
Dr. Wang's technical note: The micro-coil is not the treatment. It is the safety lock that makes the treatment possible. Without closing the shunt first, every microsphere we inject into the hepatic artery has a direct path into the portal vein. With the shunt closed, the microspheres have nowhere to go except into the tumour vasculature. The sequence — coil first, embolise second — is non-negotiable.
Phase 2 — DEB-TACE with Drug-Eluting Microspheres
Superselective catheterisation: Microcatheter advanced beyond the shunt occlusion site into the distal tumour-feeding arterial branches — as close to the tumour as anatomically possible, maximising drug delivery to the tumour while minimising exposure of non-tumour hepatic parenchyma.
Drug-eluting bead TACE: CalliSpheres microspheres (300–500 μm) loaded with epirubicin injected under fluoroscopic monitoring. DEB-TACE was selected over conventional lipiodol-based TACE for two reasons specific to this case: the uniform microsphere diameter reduces the risk of shunt passage compared to lipiodol emulsion; and the sustained drug release profile of DEB maintains intratumoural chemotherapy concentration for days rather than hours, improving tumour kill while reducing systemic toxicity. Supplementary lipiodol emulsion injected for peripheral vascular occlusion.
Endpoint: Near-complete stasis of tumour arterial flow on fluoroscopy — confirming adequate embolisation without non-target embolisation.
Phase 3 — Portal Vein Intervention (Two Weeks Later)
Indication: Post-TACE imaging confirmed main portal trunk occlusion by PVTT with intrahepatic collateral compensation. Liver function stabilised (bilirubin unchanged; albumin stable) — confirming hepatic reserve sufficient to proceed.
Percutaneous transhepatic portal vein access: Under ultrasound and fluoroscopic guidance, right portal vein accessed percutaneously via transhepatic route. Portal venogram confirmed extent of PVTT and degree of main trunk occlusion.
Portal vein stenting: Self-expanding metallic stent deployed across the PVTT segment — restoring main portal trunk patency and portal venous inflow to the liver. Restoration of portal flow reduces portal hypertension, improves hepatic synthetic function, and extends the window for further oncological treatment.
Iodine-125 seed strand brachytherapy: I-125 radioactive seed strands implanted within the PVTT under fluoroscopic guidance — delivering localised radiation to the tumour thrombus to induce thrombus regression and reduce the risk of stent re-occlusion. This combined stent-plus-brachytherapy approach is the current standard for Vp3 PVTT at Zhongshan Hospital.
Operative data: Total procedure time 120 minutes (Phase 1+2); contrast volume 80 mL (renal protection protocol); intraoperative blood loss <10 mL.
Post-procedural Course and Outcomes
- Post-embolisation syndrome: Fever 38.5°C, nausea, right upper quadrant pain — expected inflammatory response to tumour necrosis; resolved with symptomatic management within 3 days
- Liver function (Day 3): Transaminases mildly elevated (<3× upper limit of normal); bilirubin stable; albumin unchanged — confirming liver-sparing strategy was successful
- 1-month CT: Dense microsphere and lipiodol deposition within tumour; tumour volume reduced approximately 30%; areas of central necrosis confirmed
- Portal vein: Stent patent; portal flow restored; I-125 seeds in satisfactory position within PVTT
- AFP at 1 month: Declined from >1,210 to 150 ng/mL — a precipitous fall confirming effective tumour cell kill
- Systemic therapy: Lenvatinib (targeted therapy) plus PD-1 checkpoint inhibitor commenced after hepatic function stabilisation — triple therapy (TACE + targeted + immunotherapy) per current international guidelines for advanced HCC
- 18-month follow-up: Alive; disease controlled; ECOG performance status 1; returned to daily activities
Expert Commentary — Dr. Wang Jianhua
1. The AP Shunt: Converting a Contraindication into an Indication
The conventional teaching that a high-flow arterioportal shunt is an absolute contraindication to TACE reflects the limitations of conventional TACE technique — not the limitations of interventional radiology. With superselective microcatheter cannulation and micro-coil shunt occlusion, the shunt becomes a manageable anatomical challenge rather than an insurmountable barrier. The critical principle is sequencing: the shunt must be occluded before any embolic material is injected. Attempting to embolise through an open shunt is not merely ineffective — it is dangerous. Coil first. Embolise second. That sequence converts a contraindication into a technically demanding but achievable procedure.
2. Portal Vein Tumour Thrombus: From Palliative to Potentially Curative
Vp3 PVTT — thrombus extending to the main portal trunk — was historically considered a terminal finding in HCC, associated with median survival below three months and no effective treatment. The dual hepatic artery and portal vein intervention strategy has fundamentally changed that prognosis. Portal vein stenting restores hepatic perfusion and reduces portal hypertension — improving liver function and extending the treatment window. I-125 brachytherapy delivers localised radiation to the thrombus, inducing regression and reducing stent re-occlusion risk. Combined with hepatic artery TACE for the primary tumour, this dual-intervention approach achieves disease control in a population previously offered only best supportive care. In selected patients, sufficient tumour downstaging can be achieved to enable secondary resection or liver transplantation — converting a palliative case into a potentially curative one.
3. DEB-TACE vs Conventional TACE: Why the Choice of Embolic Agent Matters
Drug-eluting bead TACE offers two specific advantages over conventional lipiodol-based TACE in the high-risk anatomical setting of this case. First, the uniform microsphere diameter (300–500 μm) is too large to pass through most arterioportal shunt communications — reducing the risk of non-target portal embolisation even after micro-coil shunt occlusion. Second, the sustained drug release profile maintains intratumoural epirubicin concentration for 7–14 days, compared to the rapid washout of lipiodol-emulsified chemotherapy. In a Child-Pugh B patient where every increment of hepatic toxicity matters, the reduced systemic drug exposure of DEB-TACE is not a minor pharmacological detail — it is the difference between a procedure the liver can tolerate and one it cannot.
4. Triple Therapy: The New Standard for Advanced HCC
TACE alone is not the ceiling of treatment for advanced HCC — it is the foundation on which systemic therapy is built. The combination of TACE for locoregional tumour control, lenvatinib for anti-angiogenic and anti-proliferative systemic effect, and PD-1 checkpoint inhibition for immune-mediated tumour surveillance represents the current evidence-based standard for BCLC Stage C HCC. Each modality addresses a different aspect of tumour biology: TACE induces ischaemic necrosis and releases tumour antigens; lenvatinib suppresses VEGF-driven neovascularisation that would otherwise reperfuse the embolised tumour; PD-1 inhibition restores T-cell anti-tumour activity in the immunosuppressive tumour microenvironment. The three work synergistically. Interventional radiology is not competing with systemic oncology — it is creating the conditions under which systemic oncology can succeed.
How CMCS Shanghai Coordinated This Case
CMCS Shanghai supported Mr. Chen's family from initial inquiry through 18-month surveillance, including: pre-consultation review of external CT, AFP, liver function, and HBV-DNA records; specialist referral to Dr. Wang Jianhua at Zhongshan Hospital's Interventional Radiology Centre; bilingual interpretation throughout all consultations and procedural consent discussions; coordination of contrast-enhanced CT, DSA angiography, and pre-procedure liver function assessment; real-time procedure updates to the patient's family; post-procedure monitoring communication with daily bilingual updates during the admission; discharge planning including antiviral therapy initiation (tenofovir), lenvatinib prescription coordination, and PD-1 infusion scheduling; one-month and six-month CT surveillance coordination with AFP monitoring and results translation; and long-term multidisciplinary treatment planning with direct liaison between Dr. Wang's interventional team, the hepatology team, and the patient's family.
For international patients and their families facing advanced liver cancer in Shanghai, Dr. Wang Jianhua's team at Zhongshan Hospital represents interventional oncology expertise at the international frontier — converting cases considered untreatable elsewhere into managed, survivable disease. CMCS ensures that expertise is accessible: in the patient's language, with full transparency at every procedural step, and with continuity of care from first consultation through long-term surveillance.
This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.
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