Background/ aim <p>This study aimed to evaluate the clinical outcomes of combined transarterial chemoembolization and microwave ablation for hepatic hemangiomas, focusing on whether the benefits of this minimally invasive approach extend equally to giant (≥10 cm) as well as large (5-9.9 cm) lesions.</p> Method <p>This retrospective study included 53 patients with hepatic hemangiomas who received this combined treatment from January 2015 to January 2025. Patients were stratified by maximum tumor diameter: large hepatic hemangiomas (n = 38) and giant hepatic hemangiomas (n = 15). Outcomes assessed tumor reduction, tumor response, adverse events, and clinical and psychological symptoms.</p> Result <p>Among the 53 patients, the median tumor diameter at baseline was 8.30 cm (range: 5-19.2 cm). The median baseline tumor diameter in the large hepatic hemangiomas group was 7.3 cm (range 5-9.8 cm). In the giant hepatic hemangiomas group, the median baseline tumor diameter was 11.3 cm (range 10-19.2 cm). The median follow-up period was 35 months. Both groups achieved similarly high tumor response, with 100% objective response rate at more than three years post-treatment. Additionally, none of the 53 patients experienced hemolytic adverse effects such as hemoglobinuria or severe renal damage, highlighting the safety of this combined treatment.</p> Conclusion <p>The combined treatment delivers durable clinical outcomes across the size spectrum of hepatic hemangiomas. Giant lesions also achieved durable control without hemolysis-related complications, supporting this minimally invasive approach as a surgical alternative.</p>