Portal Vein Embolization Pre-Hepatectomy

Background and indications

Portal vein embolization (PVE) is a pre-operative procedure aimed at inducing compensatory hypertrophy of the future liver remnant (FLR) before major hepatectomy. By embolizing portal branches of the lobe to be resected, portal flow is redistributed to the contralateral lobe, stimulating regeneration. PVE is indicated when FLR is deemed insufficient (< 25-30% of total liver volume for healthy liver, < 40% for cirrhotic liver or after chemotherapy).

Pre-procedure assessment

Assessment includes hepatic CT with volumetry (FLR calculation), complete hepatic blood panel (residual liver function), and surgical tumor board discussion. Technical feasibility (pre-existing portal thrombosis?) is verified.

Procedure

Under local anesthesia and sedation, percutaneous puncture of a right portal branch is performed under ultrasound and fluoroscopic guidance. A catheter is advanced into portal branches of the lobe to be resected. Particles, coils, and/or glue are used to embolize all segmental and subsegmental portal branches. The procedure takes 1 to 2 hours.

Results and scientific evidence

PVE induces 30-60% FLR hypertrophy in 3-6 weeks, enabling surgery in 80-90% of cases. Post-operative liver failure rate is significantly reduced after PVE. The ALPPS technique (Associated Liver Partition and Portal vein ligation for Staged hepatectomy) is a surgical alternative for the most urgent cases, but with higher morbidity (Ribero et al., Annals of Surgery, 2007; DOI: 10.1097/SLA.0b013e3180986b33).

Risks and complications

Liver pain (30-50%), transient fever (10-20%), transient portal hypertension (5-10%), non-target portal thrombosis (< 2%). Major complications are rare (< 2%). Mortality is virtually nil.

Recovery

1-2 night hospitalization. Volumetric control CT at 3-4 weeks to evaluate hypertrophy. Hepatectomy planned if FLR sufficient.

Practical information

The procedure is performed as a short inpatient stay. It is performed by an interventional radiologist, in coordination with the liver surgeon and oncologist.