Portal Vein Embolization In Patients Research Articles

Effectiveness of Preoperative Sequential Transarterial Chemoembolization Followed by Portal Vein Embolization in Patients Undergoing Hepatectomy: A Meta-analysis

Effectiveness of Preoperative Sequential Transarterial Chemoembolization Followed by Portal Vein Embolization in Patients Undergoing Hepatectomy: A Meta-analysis

Associating liver partition and portal vein ligation for staged hepatectomy versus sequential transarterial chemoembolization and portal vein embolization in staged hepatectomy for HBV-related hepatocellular carcinoma: a randomized comparative study.

Both portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) have merits and demerits when used in patients with unresectable liver cancers due to insufficient volumes in future liver remnant (FLR). This study was a single-center, prospective randomized comparative study. Patients with the diagnosis of hepatitis B related hepatocellular carcinoma (HCC) were randomly assigned in a 1:1 ratio to the 2 groups. The primary endpoints were tumor resection and three-year overall survival (OS) rates. Between November 2014 to June 2016, 76 patients with unresectable HBV-related HCC due to inadequate volume of FLR were randomly assigned to ALPPS groups (n=38) and TACE + PVE groups (n=38). Thirty-seven patients (97.4%) in the ALPPS group compared with 25 patients (65.8%) in the TACE + PVE group were able to undergo staged hepatectomy (risk ratio 1.48, 95% CI: 1.17-1.87, P<0.001). The three-year OS rate of the ALPPS group (65.8%) (95% CI: 50.7-80.9) was significantly better than the TACE + PVE group (42.1%) (95% CI: 26.4-57.8) (HR 0.50, 95% CI: 0.26-0.98, two-sided P=0.036). However, no significant difference in the OS rates between patients who underwent tumor resection in the 2 groups of patients was found (HR 0.80, 95% CI: 0.35-1.83, two-sided P=0.595). Major postoperative complications rates after the stage-2 hepatectomy were 54.1% in the ALPPS group and 20.0% in the TACE + PVE group (risk ratio 2.70, 95% CI: 1.17-6.25, P=0.007). ALPPS resulted in significantly better intermediate-term OS outcomes, at the expenses of a significantly higher perioperative morbidity rate compared with TACE + PVE in patients who had initially unresectable HBV-related HCC.

Associating Portal Vein Embolization with Extended Resection Doesn’t Improve Outcomes in Surgical Management of Locally Advanced Gall Bladder Carcinoma

Introduction: Portal vein embolization(PVE) is established as a safe and effective method to increase the size of the future liver remnant(FLR) in cholangiocarcinoma, hepatocellular carcinoma and colorectal cancer liver metastasis. Results in gallbladder carcinoma(CaGB) have not been assessed comprehensively. We evaluated the outcome of PVE in patients with locally advanced CaGB.

MRI-Based Quantitation of Hepatic Steatosis Does Not Predict Hypertrophy Rate after Portal Vein Embolization in Patients with Colorectal Liver Metastasis and Normal to Moderately Elevated Fat Fraction.

The aim of this study was to correlate the pre-procedural magnetic-resonance-imaging-based hepatic fat fraction (hFF) with the degree of hypertrophy after portal vein embolization (PVE) in patients with colorectal cancer liver metastases (CRCLM). Between 2011 November and 2020 February, 68 patients with CRCLM underwent magnetic resonance imaging (MRI; 1.5 Tesla) of the liver before PVE. Using T1w chemical shift imaging (DUAL FFE), the patients were categorized as having a normal (<5%) or an elevated (>5%) hFF. The correlation of hFF, age, gender, initial tumor mass, history of chemotherapy, degree of liver hypertrophy, and kinetic growth rate after PVE was investigated using multiple regression analysis and Spearman’s test. A normal hFF was found in 43/68 patients (63%), whereas 25/68 (37%) patients had an elevated hFF. The mean hypertrophy and kinetic growth rates in patients with normal vs. elevated hFF were 24 ± 31% vs. 28 ± 36% and 9 ± 9 % vs. 8 ± 10% (p > 0.05), respectively. Spearman’s test showed no correlation between hFF and the degree of hypertrophy (R = −0.04). Multivariable analysis showed no correlation between hFF, history of chemotherapy, age, baseline tumor burden, or laterality of primary colorectal cancer, and only a poor inverse correlation between age and kinetic growth rate after PVE. An elevated hFF in a pre-procedural MRI does not correlate with the hypertrophy rate after PVE and should therefore not be used as a contraindication to the procedure in patients with CRCLM.

Safety and efficacy of right portal vein embolization in patients with prior left lateral liver resection.

In patients with bilobar metastatic liver disease, surgical clearance of both liver lobes may be achieved through multiple-stage liver resections. For patients with extensive disease, a major two-staged hepatectomy consisting of resection of liver segments II and III before right-sided portal vein embolization (PVE) and resection of segments V-VIII may be performed, leaving only segments IV ± I as the liver remnant. To describe the outcome following right-sided PVE after prior complete resection of liver segments II and III. In this retrospective study, 15 patients (mean age = 60.4 ± 9.3 years) with liver metastases from colorectal cancer (n = 14) and uveal melanoma (n = 1) who were scheduled to undergo a major two-stage hepatectomy, were included. Total liver volume (TLV) and volume of the future liver remnant (FLR) were measured on pre- and postinterventional computed tomography (CT) scans, and standardized FLR volumes (ratio FLR/TLV) were calculated. Patient data were retrospectively analyzed regarding peri- and postinterventional complications, with special emphasis on liver function tests. The mean standardized post-PVE FLR volume was 26.9% ± 6.4% and no patient developed hepatic insufficiency after the PVE. Based on FLR hypertrophy and liver function tests, all but one patient were considered eligible for the subsequent right-sided hepatectomy. However, due to local tumor progression, only 9/15 patients eventually proceeded to the second stage of surgery. . Right-sided PVE was safe and efficacious in this cohort of patients who had previously undergone a complete resection of liver segments II and III as part of a major staged hepatectomy pathway leaving only segments IV(±I) as the FLR. .

Oncological benefits of portal vein embolization for patients with hepatocellular carcinoma.

Portal vein embolization (PVE) for hepatocellular carcinoma (HCC) was first introduced in 1986 and has been continuously developed throughout the years. Basically, PVE has been applied to expand the indication of liver resection for HCC patients of insufficient future liver remnant. Importantly, PVE can result in tumor progression in both embolized and non‐embolized livers; however, long‐term survival after liver resection following PVE is at least not inferior compared with liver resection alone despite the smaller future liver remnant volume. Five‐year disease‐free survival and 5‐year overall survival were 17% to 49% and 12% to 53% in non‐PVE patients, and 21% to 78% and 44% to 72% in PVE patients, respectively. At present, it has proven that PVE has multiple oncological advantages for both surgical and nonsurgical treatments. PVE can also enhance the anticancer effects of transarterial chemoembolization and can avoid intraportal tumor cell dissemination. Additional interventional transarterial chemoembolization and hepatic vein embolization as well as surgical two‐stage hepatectomy and associated liver partition and portal vein ligation for staged hepatectomy can enhance the oncological benefit of PVE monotherapy. Taken together, PVE is an important treatment which we recommend for listing in the guidelines for HCC treatment strategies.

Simultaneous transcatheter arterial chemoembolization and portal vein embolization for patients with large hepatocellular carcinoma before major hepatectomy.

BACKGROUNDSequential transarterial chemoembolization (TACE) and portal vein embolization (PVE) are associated with long time interval that can allow tumor growth and nullify treatments' benefits.AIMTo evaluate the effect of simultaneous TACE and PVE for patients with large hepatocellular carcinoma (HCC) prior to elective major hepatectomy.METHODSFifty-one patients with large HCC who underwent PVE combined with or without TACE prior to hepatectomy were included in this study, with 13 patients in the simultaneous TACE + PVE group, 17 patients in the sequential TACE + PVE group, and 21 patients in the PVE-only group. The outcomes of the procedures were compared and analyzed.RESULTSAll patients underwent embolization. The mean interval from embolization to surgery, the kinetic growth rate of the future liver remnant (FLR), the degree of tumor size reduction, and complete tumor necrosis were significantly better in the simultaneous TACE + PVE group than in the other groups. Although the patients in the simultaneous TACE + PVE group had a higher transaminase levels after PVE and TACE, they recovered to comparable levels with the other two groups before surgery. The intraoperative course and the complication and mortality rates were similar among the three groups. The overall survival and disease-free survival were higher in the simultaneous TACE + PVE group than in the other two groups.CONCLUSIONSimultaneous TACE and PVE is a safe and effective approach to increase FLR volume for patients with large HCC before major hepatectomy.

Associating liver partition and portal vein ligation for staged hepatectomy versus portal vein embolization in staged hepatectomy for hepatocellular carcinoma: A randomized comparative study.

4578 Background: Both Portal Vein Embolization (PVE) and Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) have been used in patients with unresectable hepatocellular carcinoma (HCC) due to insufficient volumes in future liver remnant (FLR). But it remains unclear for which thetapy has better long-term overall survival. Methods: This study was a single-center, prospective randomized comparative study. Patients were randomly assigned in a 1:1 ratio to the 2 groups. The primary endpoints was three-year overall survival rates. Results: Between November 2014 to June 2016, 76 patients with unresectable HCC due to inadequate volume of FLR were randomly assigned to ALPPS groups (n = 38) and PVE groups (n = 38). Thirty-seven patients (97.4%) in the ALPPS Group compared with 25 patients (65.8%) in the PVE Group were able to undergo staged hepatectomy (risk ratio 1.48, 95% CI 1.17-1.87, p &lt; 0.001). The three-year overall survival (OS) rate of the ALPPS group (65.8%) (95% CI 50.7-80.9) was significantly better than the PVE Group (42.1%) (95% CI 26.4-57.8), (HR 0.50, 95% CI 0.26-0.98, two-sided p = 0.036). Major postoperative complications rates after the stage-2 hepatectomy were 54.1% in the ALPPS group and 20.0% in the PVE group ((risk ratio 2.70, 95% CI 1.17-6.25, p = 0.007). Conclusions: ALPPS resulted in significantly better long-term overall survival outcomes, at the expenses of a significantly higher perioperative morbidity rate compared with PVE in patients who had initially unresectable HCC. Clinical trial information: ChiCTR-IOC-14005646 .

Surgical technique and clinical results of one- or two-stage laparoscopic right hemihepatectomy after portal vein embolization in patients with initially unresectable colorectal liver metastases: A case series.

The use of the laparoscopic approach in one-stage or second-step of two-stage right hemihepatectomy (RHH) after portal vein embolization (PVE) in patients with initially unresectable colorectal liver metastases (CRLMs) is technically demanding. Currently, there is limited published data regarding the technique and results required to better understand its safety and feasibility. This paper reports our experience, results, techniques and variety of tips and tricks (highlighted in the attached video), to facilitate this resection. A prospectively maintained database of laparoscopic liver surgery within our unit at a tertiary referral centre between August 2003 and March 2019 was reviewed. Patients with initially unresectable CRLMs who underwent laparoscopic RHH or extended RHH after PVE in the context of a one or two-stage procedure were included. Between August 2003 and March 2019, 19 patients with initially unresectable CRLMs underwent laparoscopic RHH after PVE. Twelve patients (63.2%) had RHH in the context of a two-stage hepatectomy and 7 as a one-stage procedure. Median time interval between PVE and surgery was 42.5 days (IQR, 34.5-60.0 days). Mean operating time was 351.8±80.5 minutes. Median blood loss was 850 mL (IQR, 475-1350 mL). Conversion to open surgery occurred in 2 of 19 cases (10.5%). Severe postoperative morbidity occurred in 2 patients. The mortality rate was 5.3%. Median postoperative hospital stay was 5 days (IQR, 4-7 days). Radical resection was obtained in eighteen patients (94.7%). Laparoscopic RHH after PVE in the context of a one- or two-stage resection in patients with initially unresectable CRLMs is a safe and feasible procedure with favourable oncological outcomes.

One- or two-stage laparoscopic right hemihepatectomy after portal vein embolization in patients with initially unresectable colorectal liver metastases: Technical aspects and clinical results

One- or two-stage laparoscopic right hemihepatectomy after portal vein embolization in patients with initially unresectable colorectal liver metastases: Technical aspects and clinical results

4:12 PM Abstract No. 245 Safety and efficacy of sequential Y90 radioembolization and portal vein embolization in patients with hepatocellular carcinoma and metastatic colorectal cancer

The use of portal vein embolization is widely applied to induce hypertrophy of the future liver remnant in preoperative patients. Patients may not receive surgery for various reasons. The safety and efficacy of combined radioembolization and portal vein embolization is not understood. We present our experience of sequential Y90 RE and portal vein embolization. A retrospective review of patients treated with a combination of portal vein embolization and Y90 radioembolization between January 2008 and August 2019 was cataloged. Post procedure laboratory values, clinical notes, cross sectional imaging and adverse events were recorded. 14 patients (10 mCRC, 4 HCC) were treated both PVE and Y90 embolization. The mCRC patients received resin microspheres and the HCC patients received glass microspheres. 12 patients had PVE prior to Y90. Nine patients had Y90 after PVE for treatment of liver tumors after aborted surgery. Three patients had Y90 after PVE to induce further hypertrophy. Median time from PVE to Y90 was 250 days (65 – 1253). Two patients with HCC had Y90 prior to PVE with a median time from Y90 to PVE of 24 days (22 and 25). The combination treatment was performed for preoperative treatment and induction of hypertrophy. One patient was successfully resected. The median injected activity was 53 mCi (23 -139). No CTCAE 5.0 grade 3 or higher adverse events were seen at 30- and 90-day follow-up. Median survival of the entire cohort was 490 days. Treatment of HCC and metastatic CRC with a combination PVE and Y90 is safe and may be used to tumor control and induction of liver hypertrophy in select patients.

Correlation Between Sarcopenia and Growth Rate of the Future Liver Remnant After Portal Vein Embolization in Patients with Colorectal Liver Metastases

PurposeTo investigate whether sarcopenia and myosteatosis correlate with the degree of hypertrophy (DH) and kinetic growth rate (KiGR) of the future liver remnant (FLR) in patients with colorectal liver metastases undergoing portal vein embolization (PVE) in preparation for right hepatectomy.Materials and MethodsForty-two patients were included. Total liver volume and FLR volume were measured before and 2–4 weeks after PVE. KiGR of the FLR was calculated. Sarcopenia was assessed using the total psoas muscle volume (PMV), the psoas muscle cross-sectional area (PMCS) and the total skeletal muscle index (L3SMI) at the level of 3rd lumbar vertebra. Degree of myosteatosis was assessed by mean muscle attenuation at L3 (L3MA). Correlations between muscle indices and DH and KiGR were assessed using simple linear regression analyses.ResultsMean DH was 8.9 ± 5.7%, and mean KiGR was 3.6 ± 2.3. Mean PMV was 55.56 ± 14.19 cm3/m3, mean PMCS was 8.76 ± 2.3 cm2/m2, mean L3SMI was 45.6 ± 9.89 cm2/m2, and mean L3MA was 27.9 ± 18.6 HU. There was a strong positive correlation between PMV and DH (R = 0.503, p = 0.001) and PMV and KiGR (R = 0.545, p < 0.001). Furthermore, there was a moderate correlation between PMCS and KiGR (R = 0.389, p = 0.014). L3SMI and L3MA were neither associated with DH (p = 0.390 and p = 0.768, respectively) nor with KiGR (p = 0.188 and p = 0.929, respectively).ConclusionWe identified a positive correlation between PMV and PMCS, as markers for sarcopenia, and the KiGR of the FLR after PVE. PMV and PMCS might therefore aid to identify patients who are poor candidates for FLR augmentation using PVE alone.

Early functional response after portal vein embolization – difference between future liver remnant and embolized liver relative enhancement as a marker of improved hepatocellular reserve

Introduction: Hepatic functional reserve (HFR) assessment is crucial before major hepatectomy (mHep) particularly if portal vein embolization (PVE) is necessary, given the significant risk of post-hepatectomy liver failure (PHLF). Functional response of the Future Liver Remnant (FLR) to PVE probably occurs prior to volumetric changes. Magnetic Resonance Imaging with hepatic-specific contrast (MRI-HSC) is a promising tool combining both volumetric and signal intensity (SI) measurements, reflecting both liver anatomy and function. We intend to analyse the role of early MRI-HSC in the post-PVE assessment of HFR before mHep. Methods: Nine patients undergoing mHep after PVE (69.6±11 years; six men) were prospectively studied with MRI-HSC before and 10 days after PVE. We retrospectively selected eleven control patients who underwent mHep after PVE studied only with volumetry (63±12 years; six men). We measured FLR volume, degree of hypertrophy and kinetic growth rate (KGR) for both groups. We also analysed embolized liver (EL) and FLR SI and relative enhancement (RE) before and after PVE. Statistical significance with p< 0.05 (SPPS v21.0). Results: Volumetric-only parameters failed to correlate with post-hepatectomy liver function and morbidity. After PVE, EL RE significantly dropped in patients who did not develop PHLF (p=0.026). In these patients, the difference between FLR and EL RE significantly increased after PVE (p=0.012). Furthermore, FLR IS significantly decreased after PVE in patients who developed PHLF (p=0.05). Conclusion: Early changes in sectorial function assessed with MRI-HSC can be used to define response to PVE, predicting patients at risk of developing PHLF.

15-year experience in the use of portal vein embolization in patients with focal liver diseases

Background. Portal vein embolization allows increa­sing the future remnant liver in patients with malignant hepatic neoplasms, preparing for radical surgical treatment. The wide spread of this technique is interfered by the lack of a single execution algorithm. The purpose of this study was to analyze 15-year experience of preoperative portal vein embolization in patients with advanced liver tumors. Materials and methods. From 2003 to 2017 in the department of endovascular surgery of O.O. Shalimov National Institute of Surgery and Transplantology of the NAMS of Ukraine, 485 preoperative embolizations of the portal vein branches were performed in patients with liver tumors, the future remnant liver in which was below the threshold resectabi­lity level. Results. As a result of portal vein embolization, it was possible to achieve the future remnant liver increase by 88.2 % (from 237 to 446 cm3). It allowed performing the radical liver resection in 421 (86.8 %) patients. The analysis of laboratory data showed that the processes of hepatocytolysis associated with embolization and reduction of the synthetic function of the liver are reversible and complete within 3 weeks. Conclusions. Preoperative embolization of the portal vein branches makes it possible to expand the range of resectability of patients with advanced liver tumors and to reduce the risk of postoperative acute hepatic insufficiency.

Factors Affecting Left Lobe Hypertrophy after Right Portal Vein Embolization in Patients with Chronic Liver Disease

Background: Right portal vein embolization (PVE), performed either surgically or radiologically, is the main method used to induce growth of the future liver remnant (FLR) before right hemihepatectomy in patients with an insufficient future liver remnant volume (FLRV) due to chronic liver disease. The purpose of this study was to evaluate whether clinical and laboratory variables, as well as METAVIR fibrosis score, are predictive of PVE-induced growth of the FLR in patients with chronic liver disease. Methods: During the period from January 2007 to September 2014, a total of 813 patients underwent hemihepatectomy for hepatocellular carcinoma (HCC) or cholangiocarcinoma. Of those patients, 20 had an inadequate FLR and required right PVE before hemihepatectomy. None of the 20 patients had received preoperative chemotherapy or transarterial chemoembolization. Results: Of the parameters evaluated (serum levels of AST, ALT, ALP, GGT, albumin, total bilirubin, AFP, prothrombin time, Child- Pugh score, METAVIR fibrosis score and history of hepatitis B or hepatitis C infection), only the fibrosis score was associated with a significant change in the estimated rate of functional future liver remnant (%FFLR) volume (p = 0.042). Further analysis revealed that only mild (F1) and moderate (F2) degrees of fibrosis were associated with a significant increase in the FLRV (p = 0.043 and p = 0.028, respectively). Conclusion: The severity of liver fibrosis was found to be negatively correlated with the degree of FLR hypertrophy prior to portal vein embolization.

Preoperative portal vein embolization in liver cancer: indications, techniques and outcomes.

Postoperative liver failure is a severe complication of major hepatectomies, in particular in patients with a chronic underlying liver disease. Portal vein embolization (PVE) is an approach that is gaining increasing acceptance in the preoperative treatment of selected patients prior to major hepatic resection. Induction of selective hypertrophy of the non-diseased portion of the liver with PVE in patients with either primary or secondary hepatobiliary, malignancy with small estimated future liver remnants (FLR) may result in fewer complications and shorter hospital stays following resection. Additionally, PVE performed in patients initially considered unsuitable for resection due to lack of sufficient remaining normal parenchyma may add to the pool of candidates for surgical treatment. A thorough knowledge of hepatic segmentation and portal venous anatomy is essential before performing PVE. In addition, the indications and contraindications for PVE, the methods for assessing hepatic lobar hypertrophy, the means of determining optimal timing of resection, and the possible complications of PVE need to be fully understood before undertaking the procedure. Technique may vary among operators, but cyanoacrylate glue seems to be the best embolic agent with the highest expected rate of liver regeneration for PVE. The procedure is usually indicated when the remnant liver accounts for less than 25-40% of the total liver volume. Compensatory hypertrophy of the non-embolized segments is maximal during the first 2 weeks and persists, although to a lesser extent during approximately 6 weeks. Liver resection is performed 2 to 6 weeks after embolization. The goal of this article is to discuss the rationale, indications, techniques and outcomes of PVE before major hepatectomy.

Portal vein embolization effect on colorectal cancer liver metastasis progression: Lessons learned.

Colorectal liver metastasis (CRLM) is the major cause of death in patients diagnosed with colorectal cancer. The gold standard treatment of CRLM is surgical resection. Yet, in the past, more than half of these patients were deemed unresectable due to the inadequate future liver remnant (FLR). The introduction of efficient portal vein embolization (PVE) preoperatively allowed more resections of metastasis in CRLM patients by stimulating adequate liver hypertrophy. However, several experimental and clinical studies reported tumor progression after PVE which critically influences the subsequent management of these patients. The underlying pathophysiological mechanism of tumor progression post-PVE is still not fully understood. In spite of the adverse effects of PVE, it remains a potentially curative procedure in patients who would remain otherwise unresectable because of the insufficient FLR. Currently, the challenge is to halt tumor proliferation following PVE in patients who require this technique. This could potentially be achieved by either attempting to suppress the underlying oncologic stimulus or by inhibiting tumor growth once observed after PVE, without jeopardizing liver regeneration. More research is still required to better identify patients at risk of experiencing tumor growth post-PVE.

Comparison of the Effectiveness of Preoperative Portal Vein Embolization in Patients with Chronic Liver Disease: Gelfoam versus Gelfoam-Coil Combination

Comparison of the Effectiveness of Preoperative Portal Vein Embolization in Patients with Chronic Liver Disease: Gelfoam versus Gelfoam-Coil Combination

Volume Regeneration of Segments 2 and 3 After Right Portal Vein Embolization in Patients Undergoing Two-Stage Hepatectomy

BackgroundThe impact of first-stage resection on volume regeneration of segments 2 and 3 (2 + 3) after right portal vein embolization (RPVE) in patients undergoing two-stage right hepatectomy has not been investigated. MethodVolume data for segments 2 + 3 were compared between 44 patients undergoing two-stage hepatectomy and 116 undergoing single-stage hepatectomy after RPVE. ResultsThe degree of hypertrophy (difference between standardized volume of segments 2 + 3 before and after RPVE) and kinetic growth rate (degree of hypertrophy at initial volume assessment divided by the number of weeks elapsed after RPVE) were significantly lower in patients undergoing two-stage hepatectomy (median 8.6 vs 10.5 % [p = 0.01] and 1.7 vs 2.4 % [p < 0.01], respectively). Resection volume during first-stage resection was negatively correlated with standardized volume increase from the volume before first-stage resection (R2 0.546, p < 0.01). In patients undergoing two-stage hepatectomy after RPVE with segment 4 embolization, the degree of hypertrophy and kinetic growth rate were similar to those in patients undergoing single-stage hepatectomy (p = 0.17 and p = 0.08, respectively). ConclusionIn patients undergoing two-stage hepatectomy, first-stage resection impairs the dynamics of volume regeneration of segments 2 + 3 after RPVE. When two-stage extended right hepatectomy is planned, additional embolization of segment 4 provides volume hypertrophy similar to that in patients undergoing single-stage hepatectomy.

Analysis of the Efficacy of Portal Vein Embolization for Patients with Extensive Liver Malignancy and Very Low Future Liver Remnant Volume, Including a Comparison with the Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy Approach

The primary reported indication for the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) technique is in patients with very low future liver remnant volumes. Given the elevated incidence of major morbidity (40%) and liver-related mortality (12%) with ALPPS, we sought to determine the safety and efficacy of percutaneous portal vein embolization (PVE) in a similar patient population. Tumor resectability and morbidity and mortality rates were reviewed for 144 consecutive liver tumor patients with future liver remnant to body weight ratios (LR/BW) less than 0.5%. All patients were referred for preoperative percutaneous right plus segment IV PVE using embolic microspheres, with planned reassessment of the LR/BW 30 days after PVE. Post-PVE outcomes were compared with reported outcomes for ALPPS. Percutaneous PVE was successfully performed in 141 of the 144 study patients (97.9%). Adequate regeneration was observed in 139 patients (98.5%) with median post-PVE LR/BW rising from 0.33% to 0.52% (p < 0.0001), representing a per-patient median regeneration rate of 62% (range 0.3% to 379%). In total, 104 patients underwent extended right hepatectomy (n= 102) or right hepatectomy (n= 2). The remaining 40 patients (27.8%) were not resectable due to short-interval disease progression (27 patients, 18.5%), insufficient liver regeneration (5 patients, 3.5%), and medical comorbidities (8 patients, 5.6%). After resection, the following outcomes were observed: major morbidity: 33.0% (34 of 104), liver insufficiency: 12.5% (13 of 104), and 90-day liver-related mortality: 5.8% (6 of 104). These oncologic and technical results compare favorably with those of ALPPS. Based on its ability to select oncologically resectable patients and superior safety and efficacy profiles, percutaneous right+ segment IV PVE and interval surgery remains the standard of care for patients with very low future liver remnant volumes.