Portal Vein Embolization

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Pre-Procedure

Strategy: redirect portal blood flow to future liver remnant (FLR) which induces hypertrophy of the non-embolized and non-tumor bearing segments. By inducing hypertrophy, procedure designed to reduce post-op morbidity and increase the number of surgical candidates eligible to undergo hepatic resections with curative intent.

Indications:
• Hepatic malignancy (either primary or secondary) without sufficient FLR following planned liver resection
• mCRC being the most common primary

Considerations:
Ratio of future liver remnant (FLR) volume to total liver volume (TLV)
• FLR:TLV
Required FLR for 3 patient populations below:
• Cirrhosis: FLR 40% of TLV
• Injured liver by hepatic steatosis or hepatotoxic chemotherapy (platin agents): FLR 30% of TLV
• Healthy liver: FLR 20% of TLV
Anticipated surgery: right hepatectomy, extended right hepatectomy, pancreaticoduodenectomy
Preprocedural CT
• extent and location of disease
• FLR and TLV
• Anatomy of portal system

Contraindications:
• Issues which may preclude surgery: periportal lymphadenopathy or extrahepatic metastasis
• Uncorrectable coagulopathy
• Malignant portal vein invasion

Procedure

Antibiotic:
• No consensus on antibiotic but SIR guidelines recommends an antibiotic
• Consider 1g ceftriaxone or 1g vancomycin IV for preprocedure

Access:
• Ipsilateral approach: access and embolization are same side: Typically, V28 right side access for right lobe embolization
• Contralateral approach: access on opposite side of planned embolization. Potentially may injury portion of liver contributing to the future liver remnant.
• Transsplenic approach: access splenic vein near splenic hilum

Ipsilateral portal vein embolization:
• US or blind access into peripheral right portal venous branch with micropuncture set or AccuStick set (Boston Sci).
• Under US, portal veins have echogenic walls
• If blind access, use contrast judiciously
• Can aspirate for blood return
• 5 or 6-Fr sheath - BRITE tip sheaths (Cordis) helpful
• Pigtail or flush catheter for portogram to delineate anatomy. RAO to delineate right/left side. LAO to delineate anterior/posterior segments.
Upcoming surgery will dictate segments to embolize
• Right hepatectomy: embolize segments V-VIII
• Extended right hepatectomy: embolize segments IV-VIII
Reverse curve catheters helpful for access with ipsilateral approach
Microcatheters can be helpful for more distal access and to avoid reflux/non-target embolization

Many choices for embolics:
Common strategy is particles for distal embolization and coils for proximal embolization
Triascryl microspheres: 100-300 μm up to 500-700 μm.
Polyvinyl alcohol (PVA)
Embolization coils or Amplatzer vascular plug
• Leave 1 cm segment of right portal vein clear for upcoming surgical ligation
• Often used following distal embolization with particles
N-butyl cyanoacrylate (NBCA): often mixed with Lipiodol (Guerbet)
• NBCA:Lipiodol 3:1 for distal embolization
• For more distal embolization, dilute glue. Example - NBCA:Lipiodol 1:8
• More cost effective

If extended right hepatectomy, recommend embolizing segment IV first.
Embolize all necessary segments leaving the accessed segment for last.
• Embolize proximally with coils or plug
• Pull catheter peripheral to coil/plug and embolize from plug to skin
Endpoint: stasis or near stasis

Things to consider:
• If compromised liver function, obtaining portal pressures pre and post embolization - may be prognostic indicator
• If ipsilateral approach, take "completion" portogram before embolizing the accessed segment
• Depending on coagulation status and portal entry site, consider tract embolization with removal of catheter/sheath.

Post-Procedure

Complications:
Major complications are uncommon - < 2%
• Bleeding
• Hemobilia
• Infection
• Bile leak
• Nontarget embolization with thrombosis - 0.8%
Minor complications
• Fever - 37%
• Elevated liver enzymes
• Abdominal pain - 23%
• Nausea and vomiting - 2%
• Ileus - 1%

Postoperative care:
• Common to keep patient's overnight
• Bedrest 3 hours
• Monitor for bleeding, infection and pain
• IV hydration

Follow-up:
CT/MR in 2-4 weeks
• Calculate FLR hypertrophy.
• Also assess tumor burden
If target FLR not reached on first study, repeat CT/MR monthly
Tumor progression may lead to unresectability

Outcomes
• Technical success > 99%
• Normal liver: 100% increase of FLR
• 20% non-responders in cirrhotic population
• Increase of FLR:TLV ratio: 8-25% in normal livers and 6-20% in cirrhotics
• Resection rate following PVE: goal of ~85%


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References

[1] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.00[
[2] Dhaliwal SK, Annamalai G, Gafoor N, Pugash R, Dey C, David EN. Portal Vein Embolization: Correlation of Future Liver Remnant Hypertrophy to Type of Embolic Agent Used. Can Assoc Radiol J. 2018;69(3):316‐321. doi:10.1016/j.carj.2018.02.003
[3] Loffroy R, Favelier S, Chevallier O, et al. Preoperative portal vein embolization in liver cancer: indications, techniques and outcomes. Quant Imaging Med Surg. 2015;5(5):730-9.
[4] van Lienden KP, van den Esschert JW, de Graaf W, et al. Portal vein embolization before liver resection: a systematic review. Cardiovasc Intervent Radiol. 2013;36(1):25‐34. doi:10.1007/s00270-012-0440-y
[5] Avritscher R, Duke E, Madoff DC. Portal vein embolization: rationale, outcomes, controversies and future directions. Expert Rev Gastroenterol Hepatol. 2010;4(4):489‐501. doi:10.1586/egh.10.41
[6] Madoff DC, Hicks ME, Vauthey JN, et al. Transhepatic portal vein embolization: anatomy, indications, and technical considerations. Radiographics. 2002;22(5):1063‐1076. doi:10.1148/radiographics.22.5.g02se161063

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Portal Vein Embolization in Liver Cancer Patients

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Portal Vein Embolization With Professor Florian Wolf

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Seminars in Interventional Radiology (Jun 2008)

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RadioGraphics (Sep 2002)

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