Dynamic Multi-Phase-Fused Photon-Counting CT for Pre-TACE Feeding Artery Mapping and DSA Procedural Road-Mapping in Hepatocellular Carcinoma

Background/Objectives: Accurate preoperative feeding artery mapping remains challenging for hepatocellular carcinoma (HCC) even with modern CT techniques. This study aimed to optimize dynamic multi-phase photon-counting CT (PCCT) hepatic artery protocols and assess dynamic-fusion PCCT against best single-phase PCCT and energy-integrating-detector dual-energy CT (EID-DECT) for feeding artery detection, vascular-map construction and digital subtraction angiography (DSA) path-planning prior to transarterial chemoembolization (TACE) in HCC. Methods: This prospective single-center study contained workflow-optimization among cirrhotic non-HCC patients and clinical validation in TACE-candidate HCC patients. Two radiologists performed blinded independent reading. The composite reference standard consisted of DSA, selective/superselective angiography, available cone-beam computed tomography (CBCT) and embolization records. Primary endpoint: patient-level paired difference in DSA-verified feeding artery coverage. Secondary endpoints included complete-atlas rate, DSA-path-prediction accuracy, missed-vessel count and extrahepatic-supply detection. A pre-specified comparison between dynamic-fusion PCCT and EID-DECT was performed. Results: Dynamic phase 1–6 fusion was the optimal PCCT scheme, while optimal single-phase varied individually. Dynamic-fusion PCCT achieved superior feeding artery coverage (97.78% ± 8.61% vs. 88.33% ± 15.37%, difference 9.44 pp, 95% CI 1.82–17.06, p = 0.016), complete-atlas rate (93.3% vs. 53.3%, p = 0.039) and path-prediction accuracy (96.67% ± 11.18% vs. 80.00% ± 24.49%), with fewer missed culprit vessels. Two extrahepatic feeders were only detected by dynamic-fusion PCCT. Compared with EID-DECT, dynamic-fusion PCCT showed favorable atlas-related metrics without statistically significant difference in feeding artery coverage. Conclusions: Dynamic-fusion PCCT outperforms single-phase PCCT in pre-TACE feeding artery mapping and DSA path-prediction and shows potential benefits over EID-DECT. It delivers comprehensive preoperative vascular data and may reduce intraoperative exploratory procedures.