Clinical Scorecard: Enhancing Liver Volume for Safer Hepatic Surgery: An Overview of Portal and Hepatic Vein Embolization Techniques

At a Glance

Key Highlights

• Portal vein embolization (PVE) is a minimally invasive, widely accepted method to induce FLR hypertrophy and reduce postoperative liver failure risk.
• Simultaneous portal and hepatic vein embolization (PVE/HVE) is emerging to accelerate and enhance FLR hypertrophy compared to PVE alone.
• PVE has demonstrated median FLR volume increases of approximately 11–12%, improving resectability and surgical outcomes.

Guideline-Based Recommendations

Diagnosis

• Assess FLR volume preoperatively to determine risk of postoperative liver failure and need for hypertrophy induction.

Management

• Use PVE as standard preoperative intervention to induce FLR hypertrophy before major hepatectomy.
• Consider PVE/HVE to potentially achieve faster and greater hypertrophy, especially when PVE alone is insufficient.
• PVL may be used selectively during two-stage hepatectomies for bilobar colorectal liver metastases.

Monitoring & Follow-up

• Monitor FLR volume growth post-embolization to evaluate adequacy for safe hepatic resection.
• Use fluoroscopic guidance during embolization to avoid non-target embolization and manage risks of reflux or backflow.

Risks

• Risk of insufficient hypertrophy or disease progression during waiting interval after PVE (30–40% failure rate in colorectal liver metastases).
• Potential complications from embolic agents including migration and non-target embolization.
• Surgical PVL may cause inflammation and scarring complicating subsequent hepatectomy.

Patient & Prescribing Data

Patients with limited FLR volume undergoing major liver resection, particularly colorectal liver metastases and hilar bile duct carcinoma

PVE improves FLR volume by approximately 11–12%, reducing postoperative liver failure and increasing resectability; PVE/HVE may offer faster hypertrophy but requires further prospective validation.

Clinical Best Practices

• Prefer PVE over PVL due to minimally invasive nature and reduced perioperative morbidity.
• Select embolic materials carefully; NBCA mixed with Lipiodol offers rapid and permanent occlusion but requires careful technique to avoid complications.
• Consider adjunctive embolization with absolute alcohol in PVL to enhance hypertrophy response.
• Use serial imaging to assess FLR hypertrophy before proceeding with hepatic resection.

References

• Failure rate of PVE in colorectal liver metastases
• Emerging data on PVE/HVE technique
• Rous and Larimore 1920 portal vein ligation animal model
• Honjo et al. first human PVL application
• Use of PVL in two-stage hepatectomies
• Adjunctive portal vein embolization with absolute alcohol
• Kinoshita et al. introduction of PVE
• Makuuchi et al. popularization of PVE
• Comparison of PVL and PVE safety and efficacy
• Vauthey et al. FLR increase after PVE
• Azoulay et al. FLR hypertrophy data
• Embolic materials and NBCA use in PVE