Portal Vein Embolization: State-of-the-Art Technique and Options to Improve Liver Hypertrophy

Abstract

Portal vein embolization (PVE) is associated with a high technical and clinical success rate for induction of future liver remnant hypertrophy prior to surgical resection. The degree of hypertrophy is variable and depends on multiple factors, including technical aspects of the procedure and underlying chronic liver disease. For patients with insufficient liver volume following PVE, adjunctive techniques, such as intra-portal administration of stem cells, dietary supplementation, transarterial embolization, and hepatic vein embolization, are available. Our purpose is to review the state-of-the-art technique associated with high-quality PVE and to discuss options to improve hypertrophy of the future liver remnant.

Keywords: Adjunctive options; PVE; Technique.

Fig. 1

60-year-old female with cholangiocarcinoma presenting for right portal vein embolization extended to segment 4 portal veins. A balloon occlusion catheter (Fogarty®, Edwards Lifesciences, Irvine, CA, USA) is placed in segment 4A (white arrow). Injection of contrast demonstrates patent antegrade flow and no reflux. Image courtesy of Armeen Mahvash, MD.

Fig. 2

59-year-old male with metastatic colorectal carcinoma presenting for right portal vein embolization extended to segment 4 portal veins (RPVE+4) prior to extended right hepatectomy. A Completion portal venogram following embolization demonstrates sluggish but patent flow in 3 branches supplying segment 6 (black arrows). B Coronal maximum intensity projection image from a computed tomography scan performed 30 days following RPVE+4 demonstrates patent flow involving 3 branches supplying segment 6 (black arrows).

Fig. 3

50-year-old male with metastatic colon cancer to the liver status post 1st-stage segment 3 liver resection presenting for right portal vein embolization (RPVE) prior to 2nd-stage right hepatectomy. A Axial computed tomography (CT) image demonstrates the future liver remnant (FLR, outlined by white dots) measuring 511 ml. B Patient underwent RPVE with trisacryl gelatin microspheres and coils. Completion portal venogram demonstrates successful occlusion of the right portal vein branches. C Axial CT image obtained 21 days following PVE demonstrates slight increase in FLR volume to 579 ml. D Patient underwent adjunctive right hepatic vein embolization (HVE) with coils and vascular plugs. Completion venogram demonstrates occlusion of the right hepatic vein. E Axial CT image from a CT scan obtained 57 days following HVE demonstrates interval increase in FLR volume to 740 ml.