ObjectiveTo identify the risk factors for liver failure in patients with recurrent liver cancer after hepatectomy who underwent transcatheter arterial chemoembolization (TACE) therapy, and to develop a nomogram predictive model. MethodsThe patients who underwent TACE therapy for recurrent liver cancer after hepatectomy at Haian People’s Hospital Affiliated to Nantong University from December 2018 to January 2023 were retrospectively enrolled. The patients were randomly divided into a training set and a validation set in a 7∶3 ratio. The risk factors for liver failure after TACE therapy were identified using univariate and multivariate logistic regression analyses in the training set. A nomogram predictive model was then developed incorporating the identified risk factors. The discriminative ability of the nomogram predictive model was evaluated using the area under the receiver operating characteristic curve (AUC). The calibration curve and decision curve analysis (DCA) were applied to assess calibration performance and clinical utility, respectively. ResultsA total of 458 patients were included (321 in the training set, 137 in the validation set), among them, 108 (23.58%) developed liver failure. The multivariate analysis revealed seven independent predictors associated with an increased risk of liver failure (all P<0.05): diabetes mellitus, liver cirrhosis, preoperative Child-Pugh grade C, intraoperative blood transfusion and prolonged hepatic inflow occlusion, postoperative remnant liver volume <40%, as well as elevated total bilirubin (TBIL) level prior to TACE therapy. The nomogram constructed based on these factors achieved AUCs (95%CI) of 0.887 (0.843, 0.921) in the training set and 0.820 (0.735, 0.880) in the validation set. The calibration curves approximated the ideal line, and the Hosmer-Lemeshow test indicated good agreement between predictions and observations (training set: χ2=8.849, P=0.355; validation set: χ2=8.362, P=0.399). DCA demonstrated a high net clinical benefit within threshold probability ranges of 0.02–0.93 for the training set and 0.02–0.83 for the validation set. ConclusionsThe findings of this study indicate that heightened vigilance is required regarding the risk of liver failure in patients with high-risk factors following TACE therapy for liver cancer. These factors include comorbidities such as diabetes mellitus and liver cirrhosis, preoperative Child-Pugh grade C, intraoperative blood transfusion during hepatectomy and prolonged duration of hepatic inflow occlusion, postoperative small remnant liver volume, or elevated TBIL level prior to TACE therapy. The nomogram predictive model constructed based on these risk factors demonstrates favorable performance in the early prediction of liver failure risk after TACE therapy.