In 1991, a clinical literature review summarized that TAE prior to elective hepatic resection should be a good choice to high-risk patients once the HCHs had ruptured [29]. In 2001, a prospective study that evaluated the clinical and radiologic results of TAE for treating symptomatic HCHs was published by Srivastava D. N. et al. [30]. Eight patients (five males and three females) with symptomatic HCHs were treated by TAE with polyvinyl alcohol particles or Gelfoam and steel coils in single session. The largest diameter of the HCHs was 6–18 cm (9.28 ± 5.13 cm). Indications for TAE were abdominal pain (eight patients), rapid tumor enlargement (four of eight), and recurrent jaundice (one of eight). The results showed that the mean size of the tumor did not change significantly; however, symptomatic improvement was documented in all patients after TAE. It was concluded that TAE was a useful procedure in the therapy of symptomatic HCHs. In 2013, a retrospective study to evaluate the effectiveness of small-sized trisacryl gelatin microsphere embolization as a minimally invasive treatment method for patients with symptomatic FNH was reported by Birn J. et al. [34]. Twelve patients (ten women and two men; age range, 18–61 years) with a total of 17 lesions presenting with symptoms of pain were intervened with superselective embolization with 100–300 μm trisacryl gelatin microspheres during the period of 2006–2011. FNH was pathologically proven in 11 lesions from ten patients, and the other lesions exhibited the classic presentation on enhancement imaging for FNH. After TAE, seven patients showed complete relief and five patients showed partial relief of symptoms. Compared with lesion size before the procedure, mean reduction was 61 % (range, 26–90 %) on imaging after TAE 4–10 weeks. Contrast enhancement of lesions was universally decreased after TAE, with 5 of 17 lesions showing no enhancement. Due to the potentiality to malignant change or spontaneous hemorrhage, it was more active to treat HAs clinically. In 2013, a comparative study about resection, embolization, or observation for managing HA was documented by Karkar A. M. et al. [35]. Demographic and outcomes data were retrospectively collected on patients diagnosed with HA from 1992 to 2011. In total, 52 patients (45 females and 7 males) with 100 HAs were divided into single HA (n = 27), multiple HAs (n = 18), and adenomatosis (n = 7) groups. Median sizes of resected, embolized, and observed adenomas were 3.6 cm, 2.6 cm, and 1.2 cm, respectively. Forty-eight HAs were resected as a result of suspicion of malignancy (39 %) or large size (39 %); 61 % of these were solitary. Thirty-seven were embolized for suspicion of malignancy (56 %) or hemorrhage (20 %); 92 % of these were multifocal. Two out of three resected adenomas with malignancy were ≥10 cm and recurred locally (4 %, CI 1–14 %). Ninety-two percent of the embolized adenomas were effectively treated, three persisted (8.1 %, CI 2–22 %). Most observed lesions did not change over time. To draw a conclusion, solitary adenomas were often resected and the multifocal ones were frequently embolized and small ones can safely be observed routinely. Given low recurrence rates, select HAs can be considered for TAE.

Park S. Y. et al. [38] reported a clinical research about percutaneous US-guided RFA for the management of symptomatic enlarging HCHs to evaluate its feasibility, efficacy, and safety in 2011. Twenty-four patients (5 males and 19 females, with mean age of 49.5 ± 2.2 years old) with 25 HCHs with a diameter of more than 4 cm were treated by percutaneous RFA due to either the presence of symptoms or the enlargement of size compared with the previous imaging studies. The mean diameter of hemangioma was 7.2 ± 0.7 cm (4.0–15.0 cm) with 16 HCHs in the right and nine in the left lobe. Twenty-three HCHs (92.0 %) were successfully treated by RFA. The mean diameter of HCHs was decreased to 4.5 ± 2.4 cm (p < 0.001) in a serial follow-up computed tomography over a mean follow-up period of 23 ± 3.8 months (23–114 months). Symptoms related to HCH disappeared in all successfully treated patients. There were 14 side effects in ten patients including abdominal pain, indirect hyperbilirubinemia (>3.0 mg/dl), fever (38.3 °C), anemia (<10 g/dl), and ascites, which were successfully managed by conservative treatment. It is concluded that percutaneous US-guided RFA is an effective, minimally invasive, and safe procedure for the management of symptomatic enlarging HCH. An exploration to treat HAs using percutaneous RFA was reported by Rhim H. and his colleagues to assess the therapeutic efficacy and safety in 2008 [42]. Ten patients with HA proven pathologically were treated with an internally cooled RF electrode system under US guidance. Eight patients were asymptomatic and two patients had a recurrent tumor after surgical resection. The maximal diameter of the tumors was 2.25 ± 0.76 cm (range: 1.5–4.5 cm). All patients tolerated well the percutaneous RFA procedure without any incident. Contrast-enhanced computed tomography (n = 7) or US (n = 3) obtained immediately (<24 h) after the procedure revealed complete ablation of the tumor in all cases. There was no case of local tumor progression or new recurrence during the 2–35 months’ (mean, 17.5 months) follow-up period. Neither procedure-related mortality nor major complication requiring specific treatment was observed. It is concluded that percutaneous RFA can be a new potential alternative therapy for HA without overt complication.