Induction of Robust Future Liver Remnant Hypertrophy Before Hepatectomy With a Modified Liver Venous Deprivation Technique Using a Trans-venous Access for Hepatic Vein Embolization

Abstract

Purpose: Hepatic and/or portal vein embolization are performed before hepatectomy for patients with insufficient future liver remnant and usually achieved with a trans-hepatic approach. The aim of the present study is to describe a modified trans-venous liver venous deprivation technique (mLVD), avoiding the potential risks and limitations of a percutaneous approach to hepatic vein embolization, and to assess the safety, efficacy, and surgical outcome after mLVD.Materials and Methods: Retrospective single-center institutional review board-approved study. From March 2016 to June 2019, consecutive oncologic patients with combined portal and hepatic vein embolization were included. CT volumetric analysis was performed before and after mLVD to assess liver hypertrophy. Complications related to mLVD and surgical outcome were obtained from medical records.Results: Thirty patients (62.7 ± 14.5 years old, 20 men) with liver metastasis (60%) or primary liver cancer (40%) underwent mLVD. Twenty-one patients (70%) had hepatic vein anatomic variants. Technical success of mLVD was 100%. Four patients had complications (three minor and one major). FLR hypertrophy was 64.2% ± 51.3% (mean ± SD). Twenty-four patients (80%) underwent the planned hepatectomy and no surgery was canceled as a consequence of mLVD complications or insufficient hypertrophy. Fifty percent of patients (12/24) had no or mild complications after surgery (Clavien-Dindo 0–II), and 45.8% (11/24) had more serious complications (Clavien-Dindo III–IV). Thirty-day mortality was 4.2% (1/24).Conclusion: mLVD is an effective method to induce FLR hypertrophy. This technique is applicable in a wide range of oncologic situations and in patients with complex right liver vein anatomy.

Transfemoral hepatic vein access in double vein embolization – initial experience and feasibility

“…The volumetric outcome of the DVE procedure is likely not in uenced by the access per se, as long as a su cient embolization is achieved. Anatomical suitability should be the main reason to choose the route of access [3]. In cases where the anatomy of the right hepatic vein includes only a few early branches, a transhepatic access would be appropriate, as a single plug might be enough.…”

“…Most reports on DVE/LVD include cases where a transhepatic or transjugular access has been used for the hepatic vein embolization [4; 9]. Although the latest standard of practice document mentions transfemoral access as an alternative for hepatic vein embolization [1], the data is scarce with one publication mentioning one case were this access was used in a patient with multiple accessory veins [3]. Just recently a study on 23 patients comparing transjugular and transfemoral access was published [20], indicating a faster procedure time and non-inferior FLR hypetrophy in the transfemoral group.…”

Liver Venous Deprivation Using Amplatzer Vascular Plug–Assisted N-Butyl Cyanoacrylate Embolization of the Portal and Hepatic Veins: How Do I Do it?

“…24 There are four primary variant categories: (1) a large inferior right accessory vein draining directly into the IVC, (2) a small accessory of segment VII draining into the IVC, (3) branching of segmental veins close to the hepatocaval confluence, and (4) duplication of the right hepatic vein. 26 Additional less common variations of the portal and hepatic veins have been described elsewhere. [24][25][26]…”

“…26 Additional less common variations of the portal and hepatic veins have been described elsewhere. [24][25][26]…”