Diaphragmatic weakness after transcatheter arterial chemoembolization of the right inferior phrenic artery for treatment of hepatocellular carcinoma: a comparison of outcomes after N-butyl cyanoacrylate versus gelatin sponge embolization

Acta Radiol. 2022 Jan;63(1):48-58. doi: 10.1177/0284185120981771. Epub 2020 Dec 23.


Background: The inferior phrenic artery (IPA) is the most common extrahepatic feeder for hepatocellular carcinoma (HCC) during transhepatic arterial chemoembolization (TACE).

Purpose: To compare the incidence of diaphragmatic weakness in patients with HCC after TACE of the right IPA conducted using either N-butyl cyanoacrylate (NBCA) or gelatin sponge particles.

Material and methods: Medical records of 111 patients who underwent TACE of the right IPA using NBCA were retrospectively reviewed and compared with data from 135 patients with IPA embolization using gelatin sponge particles.

Results: The incidence of diaphragmatic weakness after the initial TACE procedure did not significantly differ between the groups (NBCA group 16.2%; gelatin sponge group 20.7%; P = 0.458). Five patients in the NBCA group and 11 in the gelatin sponge group showed spontaneous resolution of diaphragmatic weakness after a mean period of 3.5 months. Diaphragmatic weakness developed after the initial follow-up visit in 17 patients from the gelatin sponge group due to repeated TACE of the right IPA (mean 2.4 sessions; range 2-4 sessions), while it spontaneously developed without additional TACE procedures in one patient from the NBCA group. Permanent diaphragmatic weakness was less common in the NBCA than in the gelatin sponge group (12.6% and 25.2%, respectively; P = 0.017). The complete response rate did not significantly differ between the groups (NBCA group 16.2%; gelatin sponge group 25.9%; P = 0.065).

Conclusion: Use of NBCA rather than gelatin sponge particles for TACE of the right IPA resulted in a lower incidence of permanent diaphragmatic weakness.

Keywords: Hepatocellular carcinoma; N-butyl cyanoacrylate; diaphragmatic weakness; inferior phrenic artery; transcatheter arterial chemoembolization.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Carcinoma, Hepatocellular / therapy*
  • Chemoembolization, Therapeutic / adverse effects*
  • Diaphragm / blood supply*
  • Diaphragm / physiopathology*
  • Enbucrilate / adverse effects*
  • Female
  • Gelatin Sponge, Absorbable / adverse effects*
  • Humans
  • Liver Neoplasms / therapy*
  • Male
  • Middle Aged
  • Retrospective Studies


  • Enbucrilate