AIM: To determine the effectiveness of pre-liver transplant (LT) transarterial embolization (TAE) in treating hepatocellular carcinoma (HCC) and the patient categories,which are likely to have a good outcome after LT.METHODS: Twenty-nine patients with hepatitis-related cirrhosis and unresectable HCC after LT were studied over a 7-year period. The patients were divided into two groups: group A patients (19/29) received pre-LT TAE,whereas group B (10/29) underwent LT without prior TAE.According to Milan criteria, group A patients were further subdivided into: group A1 (12/19) who met the criteria,and group A2 (7/19) who did not. Patient survivals were compared.RESULTS: In the explanted liver, CT images correlated well with pathological specimens showing that TAE induced massive tumor necrosis (＞85%) in 63.1% of patients in group A and all 7 patients in group A2 exhibited tumor downgrading that met Milan criteria. The overall 5-year actuarial survival rate was 80.6%. The TAE group had a better survival (84% at 5 years) than the non-TAE (75% at 4 years). The 3-year survival of group A2 (83%)was also higher than that of group A1 (79%). Tumor necrosis ＞85% was associated with excellent survival of 100% at 3 years, which was significantly better than the others who showed ＜85% tumor necrosis (57.1% at 3 years) or who did not have TAE (75% at 3 years).CONCLUSION: TAE is an effective treatment for HCC before LT. Excellent long-term survival was achieved in patients that did not fit Milan criteria. Our results broadened and redefined the selection policy for LT among patients with HCC. Meticulous pre-LT TAE helps in further reducing the rate of dropout from waiting lists and should be considered for patients with advanced HCC.