Abstract
BackgroundSimultaneous portal vein embolization (PVE) and hepatic vein embolization (HVE) has been shown to be feasible, safe and lead to a faster growth of future liver remnant (FLR) than PVE alone. The objective of this study is to highlight different technical aspects as well as importance of embolization order.Materials and methodsSeven patients were treated with simultaneous PVE and HVE. In three cases, HVE was performed first followed by PVE and in four cases the other way around. Portal vein branches were embolized using Glubran-Lipiodol mixture in all cases. Hepatic veins were embolized using Amplatzer II plugs sized 8–20 mm. Specific consideration was given to depth of glue penetration in the portal vein defined by visible branch order on the treated side.ResultsSix of seven patients were discharged home the same day. One patient with infected tumor necrosis died of liver failure 40 days later, otherwise there were no periprocedural clinical complications. Median glue penetration was to the 5th order (4th – 5th) when PVE was performed first and 3rd order (2nd - 4th) when PVE was performed after HVE. In one PVE first case, glue spillage was seen due to marked reduced flow in the right portal vein. There was sufficient FLR growth for subsequent surgical resection in the remaining six patients.ConclusionPVE should be performed prior to HVE because the reduced flow in the portal vein after HVE leads to less deep glue penetration with presumably increased risk of contralateral spillage.
Highlights
Liver resection is the first-line treatment for many primary and secondary liver malignancies, but can be associated with significant perioperative morbidity and mortality, with the main reason being inadequate volume of the future liver remnant (FLR) leading to post-hepatectomy liver failure
Median glue penetration was to the 5th order (4th – 5th) when portal vein embolization (PVE) was performed first and 3rd order (2nd - 4th) when PVE was performed after hepatic vein embolization (HVE)
In one PVE first case, glue spillage was seen due to marked reduced flow in the right portal vein
Summary
Liver resection is the first-line treatment for many primary and secondary liver malignancies, but can be associated with significant perioperative morbidity and mortality (van Lienden et al 2013), with the main reason being inadequate volume of the future liver remnant (FLR) leading to post-hepatectomy liver failure. Several techniques have been developed to induce hypertrophy of the FLR, thereby increasing the likelihood of Recently, combined simultaneous embolization of portal and hepatic veins has been described and first studies show it to be a safe and feasible technique with faster growth rates than PVE alone (Guiu et al 2016; Guiu et al 2017; Kobayashi et al 2020). As previously for PVE, several techniques with different embolization materials have been developed for HVE. The liver venous deprivation technique (Guiu et al 2016) aims to prevent formation of distal venous-venous collaterals after hepatic vein embolization. Simultaneous portal vein embolization (PVE) and hepatic vein embolization (HVE) has been shown to be feasible, safe and lead to a faster growth of future liver remnant (FLR) than PVE alone. The objective of this study is to highlight different technical aspects as well as importance of embolization order
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