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Portal Vein Embolization

Portal Vein Embolization Procedure Prep

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Pre-Procedure Prep

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

Portal Vein Embolization Podcasts

Listen to leading physicians discuss portal vein embolization on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Procedure Steps

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%

Post-Operative Care

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

Follow-Up

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

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%

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] May BJ, Talenfeld AD, Madoff DC. Update on portal vein embolization: evidence-based outcomes, controversies, and novel strategies. J Vasc Interv Radiol. 2013 Feb;24(2):241-54. doi: 10.1016/j.jvir.2012.10.017. Epub 2013 Jan 28. PMID: 23369559.
[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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