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Fig. 1. —Decision tree shows study design of percutaneous ethanol injection guided by CO₂-enhanced sonography. We performed four examinations (marked with one asterisk) only for hypervascular hepatocellular carcinoma (HCC) lesions after initial treatment. We performed all four examinations (marked with two asterisks) in patients whose local treatment was incomplete and in cases of new HCC lesions. We performed percutaneous ethanol injection guided by CO₂-enhanced sonography (•) in patients who had a hypervascular HCC lesion on CO₂-enhanced sonography and who had poor liver function due to advanced cirrhosis; in patients who had a hypovascular or faint tumor stain on digital subtraction arteriography; and in patients in whom transcatheter arterial embolization would be difficult because of stenosis or occlusion of hepatic artery as a result of repeated transcatheter arterial embolization.