To assess the clinical efficacy and safety of transarterial chemoembolization (TACE) combined with cone-beam computed tomography (CBCT)–guided percutaneous ethanol injection (PEI) performed simultaneously for small hepatocellular carcinomas (HCCs) located in high-risk areas.

A retrospective study was conducted on 61 patients (64 lesions) with high-risk HCC who underwent simultaneous CBCT-guided TACE and PEI at the Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, between January 2019 and December 2023. Follow-up evaluations were performed at 1, 3, 6, and 12 months after treatment. Complete ablation was determined based on the absence of arterial enhancement according to mRECIST criteria. The initial complete ablation rate, secondary complete ablation rate, and final complete ablation rate were calculated. Recurrence-free survival (RFS), local tumor progression (LTP), and adverse events were also analyzed.

The technical success rate was 100%. The initial complete ablation rate was 93.8% (60/64). Four lesions did not achieve complete ablation after the initial treatment; all subsequently achieved complete ablation following additional PEI, resulting in a final complete ablation rate of 100%. At the end of follow-up, among 61 patients (64 lesions), the overall tumor recurrence rate was 44.3% (27/61), and the incidence of LTP was 19.7% (12/61). The mean RFS was 34.75 months (95% CI: 28.99–40.50), and the mean time to LTP was 45.33 months (95% CI: 39.51–51.15). Both univariate and multivariate analyses demonstrated that maximum tumor diameter (≥2 cm and <3 cm) was an independent risk factor for RFS (P < 0.001). No severe treatment-related adverse events occurred during or after the procedure.

Simultaneous TACE combined with CBCT-guided PEI is a safe and effective therapeutic approach for small HCCs in high-risk anatomical locations, achieving excellent tumor control with minimal complications.