Bariatric Embolization of Arteries in Obese Patients With HCC to Allow Salvage Liver Transplantation

February 4, 2025 updated by: Keith Pereira, MD:, St. Louis University

A Single Center, Non-randomized Study to Evaluate the Safety and Efficacy of Left Gastric Artery Embolization in Obese Patients With Hepatocellular Carcinoma to Achieve Appropriate Weight Loss That May Allow Them to be Transplanted

Hepatocellular carcinoma (HCC) is the most common primary malignant liver tumor and has a grave prognosis. Obesity is an epidemic in the US.Patients with HCC and obesity are not candidates for liver transplantation, depriving them of the best option for cure from HCC.

Recent studies have shown that blocking blood vessels to a particular portion of the stomach (bariatric or left gastric artery embolization) can temporarily decrease levels of the appetite inducing hormone ghrelin, and result in weight loss.The purpose of this study is to determine if Left gastric artery embolization (LGAE) in patients with cirrhosis and HCC who are not transplant candidates due to morbid obesity, leads to clinically significant weight loss with eligibility for liver transplantation.

Study Overview

Status

Suspended

Conditions

Intervention / Treatment

Detailed Description

Obesity:In adults, obesity is defined as a BMI of greater than 30 kg/m2. It is estimated that, by the year 2030, 38% of the world's adult population will be overweight and another 20% obese .An expert panel convened by the NIH stated that for the first time in history, the steadily improving worldwide life expectancy could level off or even decline, as the result of increasing obesity.

Liver cirrhosis with portal hypertension and HCC:

The problem: Hepatocellular carcinoma (HCC) is the most common primary malignant liver tumor seen in the setting of cirrhosis, which itself can be of varying etiology. NASH as cause for liver cirrhosis and HCC has been growing in last decade. Although Hepatitis C is currently the most common indication for liver transplant, longitudinal trends show that NASH has a trajectory to become the most common.

Current options in management: Patients who develop HCC in the context of underlying chronic liver disease complicated by portal hypertension are not candidates for resection therapy; rather, orthotopic liver transplantation (OLT) offers the best option for cure and long-term survival. Most transplant centers have strict criteria for OLT; one of the most common is a BMI < 35 kg/m2. Most NASH patients with HCC will have a high BMI. Unfortunately in presence of HCC these patients have a very limited time to lose enough weight to qualify to be listed. Lifestyle modification and medical therapies are relatively ineffective. Bariatric surgery is contraindicated in patients with portal hypertension due to significant increase in post-operative mortality, more relevant in patient listed to liver transplantation.

Thus a safe and effective minimally invasive option is needed. Based on currently available data, Left gastric artery embolization (LGAE) appears effective in inducing weight loss of about 10.5% in 3-6 months, with a high safety profile. In patients who have cirrhosis and portal hypertension with HCC and who are not transplant candidates due to morbid obesity , appropriate and timely weight loss of 10.5% in 3-6 months by performing LGAE may allow them to be listed and transplanted before their cirrhosis and tumor reaches an inoperable stage( within Milan criteria). In patients with HCC, the procedure can be performed concurrently with the procedure of Trans arterial chemoembolization which is commonly used in down staging HCC to Milan criteria.

Study Type

Interventional

Enrollment (Estimated)

8

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Missouri
      • Saint Louis, Missouri, United States, 63110
        • Saint Louis University

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years to 65 years (Adult, Older Adult)

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Male or Female, aged 18 years or older.
  • Willing, able and mentally competent to provide written informed consent and willing to comply with all study procedures and be available for the duration of the study
  • BMI >35 kg/m2

  • Adequate hematological, hepatic and renal function as follows:

    • Hematological: Platelets > 50 x 109/L, INR <1.5
    • Hepatic : Total bilirubin <3 mg/dL
    • Renal: Estimated GFR > 60ml/min.1.73m2
  • Clinical, laboratory and radiographic evidence (ultrasound/ CT/MRI) of cirrhosis of any etiology with portal hypertension and concomitant HCC (treated or untreated).
  • Besides a BMI >35 kg/m2, otherwise eligible for liver transplantation
  • Suitable for protocol therapy as determined by the interventional radiology Investigator.

Exclusion Criteria:

  • Pregnancy
  • Active substance abuse
  • Significant psychiatric problems, severe enough to cause suffering or a poor ability to function in life. Center for Epidemiological Studies Depression (CESD) score < 16.
  • Significant alcohol consumption ( >20 g/day in women, >30 g/day in men)
  • Weight > 400 lbs.
  • Presence of systemic illness or other medical conditions relevant to survival .(Note that the presence of HCC will not be considered an exclusion criteria)
  • Metastatic cancer
  • Evidence of decompensated liver disease (uncontrolled ascites, or uncontrolled spontaneous encephalopathy)
  • prior surgical weight loss procedures including gastroplasty, jejunoileal, or jejunocolic bypass, total parenteral nutrition within the past 6 months; Prior history of gastric pancreatic, hepatic, and/or splenic surgery
  • Prior embolization to the stomach, spleen or liver.
  • If review of available prior imaging studies (i.e. CT, MRI, or US) shows potential anatomical variations, presence of severe atheromatous disease, large arteriovenous shunting of blood.
  • Abnormal Endoscopy - large sliding hiatal hernia or paraesophageal hernia, active peptic ulcer disease, active H. pylori infection
  • History of abnormal Nuclear Gastric Motility examination-defined as delayed emptying of gastric contents > 90%, 60% and 10% at 1 hour, 2 hours, and 4 hours respectively.
  • ASA Class 4 or 5
  • Child Pugh classification C

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: N/A
  • Interventional Model: Single Group Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: HCC-Left gastric artery embolization
Embospheres Microspheres as artificial embolic agent for left gastric artery embolization
Device: Embospheres Microspheres
Via a radial artery in the wrist or the femoral artery in the groin, arterial access will be obtained.Under live X-ray monitoring and using contrast, a catheter will be advanced into the artery of the stomach (left gastric artery). A CT scan will be performed on the X ray table to confirm the placement of catheter. Once this is confirmed small micro spherical particles (Embosphere Microspheres beads) will be injected though the catheter to occlude the artery and cut off blood supply to the stomach. Once the procedure is complete, in case of wrist access compression will be achieved with a band; in case of groin access a closure device will be used to plug the site of entry
Other Names:
  • Bariatric embolization

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Weight
Time Frame: 12 months
Total body weight loss > 10 % in 12 months
12 months

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Clinical parameter- Abdominal circumference
Time Frame: 12 months
Improvement in abdominal circumference measured in centimeters (cm)
12 months
Clinical parameter-Blood pressure
Time Frame: 12 months
Improvement in blood pressure measured in mmHg
12 months
Laboratory parameter-Ghrelin and other serum obesity hormones(Leptin, GLP-1, PYY)
Time Frame: 12 months
Reduction in serum Ghrelin and other serum obesity hormones(Leptin, GLP-1, PYY) measured in pg/mL
12 months
Laboratory parameter-serum glucose
Time Frame: 12 months
Reduction in serum glucose levels measured as mg/dL
12 months
Laboratory parameters- HbA1c
Time Frame: 12 months
Reduction in HbA1c measures as percentage(%)
12 months
Laboratory parameters-Lipid profile
Time Frame: 12 months
Improvement in lipid profile measured as mg/dL
12 months
Number of patients with clinical adverse events
Time Frame: 12 months
Symptoms: pain, nausea, vomiting ;Adverse effects: Expected and unexpected
12 months
Number of patients with abnormal endoscopies
Time Frame: 12 months
Photos and clinical reports analyzed for ulcers
12 months
Eligibility for liver transplant
Time Frame: 12 months

Weight loss to lower BMI< 35 kg/m2 to be eligible for transplant or receive a new liver transplant.

Proportion of patients that achieved appropriate weight reduction to be listed for transplantation.
12 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

St. Louis University

Investigators

  • Principal Investigator: Kirubahara Vaheesan, MD, Associate professor of radiology-Interventional radiology
  • Principal Investigator: Alex Befeler, MD, Professor of internal medicine- Gastreoenterology
  • Principal Investigator: Mustafa Nazzal, MD, Assistant Professor of Surgery- abdominal transplant
  • Principal Investigator: Keith Pereira, MD, Assistant professor of radiology-Interventional radiology

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

October 18, 2017

Primary Completion (Estimated)

December 1, 2026

Study Completion (Estimated)

December 1, 2027

Study Registration Dates

First Submitted

October 11, 2016

First Submitted That Met QC Criteria

October 13, 2016

First Posted (Estimated)

October 17, 2016

Study Record Updates

Last Update Posted (Actual)

March 25, 2025

Last Update Submitted That Met QC Criteria

February 4, 2025

Last Verified

February 1, 2025

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 27420- HCC

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

Yes

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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