Portal and hepatic vein embolization prior to major hepatectomy

Abstract

Purpose To analyze safety and effectiveness of simultaneous portal and hepatic vein embolization (PHVE) or sequential hepatic vein embolization (HVE) compared to portal vein embolization (PVE) for future remnant liver (FRL) hypertrophy prior to major hepatic surgery. Methods Patients undergoing PVE, PHVE or HVE at our tertiary care center between 2018 and 2020 were retrospectively included. FRLV, standardized FRLV (sFRLV) and sFRLV growth rate per day were assessed via volumetry, as well as laboratory parameters. Results 36 patients (f = 15, m = 21; median 64.5 y) were included, 16 patients received PHVE and 20 patients PVE, of which 4 received sequential HVE. Significant increase of FRLV was achieved with both PVE and PHVE compared to baseline (p < 0.0001). sFRLV growth rate did not significantly differ following PHVE (2.2 ± 1.2 %/d) or PVE (2.2 ± 1.7 %/d, p = 0.94). Left portal vein thrombosis (LPVT) was observed after PHVE in 6 patients and in 1 patient after PVE. Sequential HVE showed a considerably high growth rate of 1.42 ± 0.45 %/d after PVE. Conclusion PHVE effectively induces FRL hypertrophy but yields comparable sFRLV to PVE. Sequential HVE further induces hypertrophy after insufficient growth due to PVE. Considering a potentially higher rate of LPVT after PHVE, PVE might be preferred in patients with moderate baseline sFRLV, with optional sequential HVE in non-sufficient responders.

Role of liver augmentation prior to hepatic resection – standards, procedures and indications in Germany, Switzerland, and Austria

“…FLR has been shown as a major predictor among blood transfusion, hepatic parenchyma quality and BMI of posthepatectomy liver failure [1,13,20]. To avoid post-hepatectomy liver failure because of an insu cient FLR, which is considered the main cause of mortality after major liver resection [21], at minimum a ratio of FLR to body weight of 0.5 is needed [8,9].…”

“…On the other hand, kinetic growth rate is relatively low and may take inadequately long periods of time considering the underlying oncological disease that is for this period left untreated. Consequently, augmentation of PVE by embolization the hepatic vein and segment IV have been suggested to allow a faster increase for two-staged hepatectomy [12,13]. To analyze whether PVE/HVE accelerates further growth, the recruiting DRAGON 2 trial compares PVE to PVE/HVE in a randomized controlled trial [33].…”

“…Complications due to non-targetembolization after PVE are rarely seen (all countries, n = 35/40, 87.5%), con rming PVE as safe. If FLR was considered insu cient after PVE, additional HVE might be performed[12,13]. However, in Germany and Switzerland 32.1% (n = 9/28) and 44.4% (n = 4/9), respectively, never combined PVE and HVE.…”

Multi-organ Radiomics-Based Prediction of Future Remnant Liver Hypertrophy Following Portal Vein Embolization

“…Interventional procedures were performed as previously described. 19 Briefly, a right-sided segmental portal vein branch was punctured with a 21G Chiba needle (Boston Scientific, Miami, FL, USA) under ultrasound guidance, followed by introduction of a 5F sheath (Accustick, Boston Scientific). A 6F 45 cm sheath was then introduced via an ultra-stiff .038 inch guidewire.…”

“… 20 FRLV was defined as segments II–III in all patients to ensure homogeneity of the study cohort. Furthermore, literature-based standardized FRLV (sFRLV), 19 , 21 where FRLV is calculated in relation to total liver volume based on body surface area (BSA), was calculated as: sFRLV [%] = FRLV / (−794.41 + 1267.28 × BSA) × 100 with BSA = [weight (kg) × height (cm)/3600]. 22 This method has the advantage of avoiding errors due to the subtraction of multiple tumors, the inclusion of non-functional liver with dilated ducts in the measurements, and the use of a different denominator between pre- and post-PVE total liver volume.…”