Balloon-Occlusion Versus End-Hole Transarterial Chemoembolization for Hepatocellular Carcinoma: A Systematic Review and Meta-analysis

Purpose: To evaluate the efficacy and safety of balloon-occluded transarterial chemoembolization (B-TACE) compared with conventional (cTACE) and drug-eluting-bead transarterial chemoembolization (DEB-TACE) in patients with hepatocellular carcinoma. Materials and Methods: A systematic review and meta-analysis was conducted following PRISMA guidelines and registered in PROSPERO. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to 8 February 2026 for randomized and observational studies comparing B-TACE with cTACE or DEB-TACE. Tumor response (mRECIST), overall survival, and adverse events were pooled using random-effects models; risk of bias was assessed with established tools. Results: Nine studies (one randomized, eight observational; 1534 patients) were included. Complete response, objective response, disease control, and progressive disease did not differ significantly between groups, with moderate-to-substantial heterogeneity. Baseline tumors were larger in the balloon-occluded group (mean difference 4.34 mm; 95% CI 1.18- 7.50; p = 0.014). Exploratory study-level analyses suggested greater relative B-TACE effects with larger tumors, particularly for complete response and disease control.Overall survival favored B-TACE in the two studies with extractable hazard ratios (HR 0.41; 95% CI 0.23 to 0.73; p = 0.002). Post-treatment liver enzymes, bilirubin, fever, and post-embolization syndrome did not differ significantly. Conclusion: No statistically significant differences in imaging response or safety were observed between intervention and comparator groups, while B-TACE was associated with a signal toward improved overall survival despite larger baseline tumors. Exploratory findings suggested that larger tumor size may be associated with a greater relative B-TACE effect. Given the limited evidence, these findings require confirmation in randomized controlled trials.