Portal Vein Embolization: Rationale, Technique, and Current Application

 

 Buy Article Permissions and Reprints

Abstract

Portal vein embolization (PVE) is a technique used before hepatic resection to increase the size of liver segments that will remain after surgery. This therapy redirects portal blood to segments of the future liver remnant (FLR), resulting in hypertrophy. PVE is indicated when the FLR is either too small to support essential function or marginal in size and associated with a complicated postoperative course. When appropriately applied, PVE has been shown to reduce postoperative morbidity and increase the number of patients eligible for curative intent resection. PVE is also being combined with other therapies in novel ways to improve surgical outcomes. This article reviews the rationale, technical considerations, and current use of preoperative PVE.

• References

• 1 Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin 2010; 60 (5) 277-300
  CrossrefPubMedGoogle Scholar
• 2 Bosch FX, Ribes J, Díaz M, Cléries R. Primary liver cancer: worldwide incidence and trends. Gastroenterology 2004; 127 (5) (Suppl. 01) S5-S16
  CrossrefPubMedGoogle Scholar
• 3 Ng KK, Vauthey JN, Pawlik TM , et al; International Cooperative Study Group on Hepatocellular Carcinoma. Is hepatic resection for large or multinodular hepatocellular carcinoma justified? Results from a multi-institutional database. Ann Surg Oncol 2005; 12 (5) 364-373
  CrossrefPubMedGoogle Scholar
• 4 Shoup M, Gonen M, D'Angelica M, Jamagin WR, DeMatteo RP, Schwartz LH , et al. Volumetric analysis predicts hepatic dysfunction in patients undergoing major liver resection. J Gastrointest Surg 2003; 7 (3) 325-330
  CrossrefPubMedGoogle Scholar
• 5 Ribero D, Abdalla EK, Madoff DC, Donadon M, Loyer EM, Vauthey JN. Portal vein embolization before major hepatectomy and its effects on regeneration, resectability and outcome. Br J Surg 2007; 94 (11) 1386-1394
  CrossrefPubMedGoogle Scholar
• 6 Fausto N, Campbell JS, Riehle KJ. Liver regeneration. Hepatology 2006; 43 (2) (Suppl. 01) S45-S53
  CrossrefPubMedGoogle Scholar
• 7 Michalopoulos GK. Liver regeneration. J Cell Physiol 2007; 213 (2) 286-300
  CrossrefPubMedGoogle Scholar
• 8 Taub R. Liver regeneration: from myth to mechanism. Nat Rev Mol Cell Biol 2004; 5 (10) 836-847
  CrossrefPubMedGoogle Scholar
• 9 Schweizer W, Duda P, Tanner S , et al. Experimental atrophy/hypertrophy complex (AHC) of the liver: portal vein, but not bile duct obstruction, is the main driving force for the development of AHC in the rat. J Hepatol 1995; 23 (1) 71-78
  CrossrefPubMedGoogle Scholar
• 10 Goto Y, Nagino M, Nimura Y. Doppler estimation of portal blood flow after percutaneous transhepatic portal vein embolization. Ann Surg 1998; 228 (2) 209-213
  CrossrefPubMedGoogle Scholar
• 11 Huh CG, Factor VM, Sánchez A, Uchida K, Conner EA, Thorgeirsson SS. Hepatocyte growth factor/c-met signaling pathway is required for efficient liver regeneration and repair. Proc Natl Acad Sci U S A 2004; 101 (13) 4477-4482
  CrossrefPubMedGoogle Scholar
• 12 Michalopoulos GK, DeFrances MC. Liver regeneration. Science 1997; 276 (5309) 60-66
  CrossrefPubMedGoogle Scholar
• 13 Ikeda K, Kinoshita H, Hirohashi K, Kubo S, Kaneda K. The ultrastructure, kinetics and intralobular distribution of apoptotic hepatocytes after portal branch ligation with special reference to their relationship to necrotic hepatocytes. Arch Histol Cytol 1995; 58 (2) 171-184
  CrossrefPubMedGoogle Scholar
• 14 Makuuchi M, Thai BL, Takayasu K , et al. Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report. Surgery 1990; 107 (5) 521-527
  Google Scholar
• 15 Hirai I, Kimura W, Fuse A, Suto K, Urayama M. Evaluation of preoperative portal embolization for safe hepatectomy, with special reference to assessment of nonembolized lobe function with 99mTc-GSA SPECT scintigraphy. Surgery 2003; 133 (5) 495-506
  CrossrefPubMedGoogle Scholar
• 16 Uesaka K, Nimura Y, Nagino M. Changes in hepatic lobar function after right portal vein embolization. An appraisal by biliary indocyanine green excretion. Ann Surg 1996; 223 (1) 77-83
  Google Scholar
• 17 Ijichi M, Makuuchi M, Imamura H, Takayama T. Portal embolization relieves persistent jaundice after complete biliary drainage. Surgery 2001; 130 (1) 116-118
  CrossrefPubMedGoogle Scholar
• 18 Abulkhir A, Limongelli P, Healey AJ , et al. Preoperative portal vein embolization for major liver resection: a meta-analysis. Ann Surg 2008; 247 (1) 49-57
  CrossrefPubMedGoogle Scholar
• 19 Abdalla EK, Hicks ME, Vauthey JN. Portal vein embolization: rationale, technique and future prospects. Br J Surg 2001; 88 (2) 165-175
  CrossrefPubMedGoogle Scholar
• 20 Vauthey JN, Abdalla EK, Doherty DA, Gertsch P, Fenstermacher MJ, Loyer EM , et al. Body surface area and body weight predict total liver volume in Western adults. Liver Transpl 2002; 8 (3) 233-240
  CrossrefPubMedGoogle Scholar
• 21 Johnson TN, Tucker GT, Tanner MS, Rostami-Hodjegan A. Changes in liver volume from birth to adulthood: a meta-analysis. Liver Transpl 2005; 11 (12) 1481-1493
  CrossrefPubMedGoogle Scholar
• 22 Abdalla EK, Barnett CC, Doherty D, Curley SA, Vauthey JN. Extended hepatectomy in patients with hepatobiliary malignancies with and without preoperative portal vein embolization. Arch Surg 2002; 137 (6) 675-680 ; discussion 680–671
  CrossrefPubMedGoogle Scholar
• 23 Kubota K, Makuuchi M, Kusaka K , et al. Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumors. Hepatology 1997; 26 (5) 1176-1181
  PubMedGoogle Scholar
• 24 Kishi Y, Abdalla EK, Chun YS , et al. Three hundred and one consecutive extended right hepatectomies: evaluation of outcome based on systematic liver volumetry. Ann Surg 2009; 250 (4) 540-548
  CrossrefPubMedGoogle Scholar
• 25 de Meijer VE, Kalish BT, Puder M, Ijzermans JN. Systematic review and meta-analysis of steatosis as a risk factor in major hepatic resection. Br J Surg 2010; 97 (9) 1331-1339
  CrossrefPubMedGoogle Scholar
• 26 McCormack L, Petrowsky H, Jochum W, Furrer K, Clavien PA. Hepatic steatosis is a risk factor for postoperative complications after major hepatectomy: a matched case-control study. Ann Surg 2007; 245 (6) 923-930
  CrossrefPubMedGoogle Scholar
• 27 Vauthey JN, Pawlik TM, Ribero D, Wu TT, Zorzi D, Hoff PH , et al. Chemotherapy regimen predicts steatohepatitis and an increase in 90-day mortality after surgery for hepatic colorectal metastases. J Clin Oncol 2006; 24 (13) 2065-2072
  Google Scholar
• 28 Shirabe K, Shimada M, Gion T , et al. Postoperative liver failure after major hepatic resection for hepatocellular carcinoma in the modern era with special reference to remnant liver volume. J Am Coll Surg 1999; 188 (3) 304-309
  CrossrefPubMedGoogle Scholar
• 29 Farges O, Belghiti J, Kianmanesh R , et al. Portal vein embolization before right hepatectomy: prospective clinical trial. Ann Surg 2003; 237 (2) 208-217
  Google Scholar
• 30 Madoff DC, Abdalla EK, Vauthey JN. Portal vein embolization in preparation for major hepatic resection: evolution of a new standard of care. J Vasc Interv Radiol 2005; 16 (6) 779-790
  CrossrefPubMedGoogle Scholar
• 31 Abdalla EK, Denys A, Chevalier P, Nemr RA, Vauthey JN. Total and segmental liver volume variations: implications for liver surgery. Surgery 2004; 135 (4) 404-410
  CrossrefPubMedGoogle Scholar
• 32 Shimura T, Suehiro T, Suzuki H, Okada K, Araki K, Kuwano H. Trans-ileocecal portal vein embolization as a preoperative treatment for right trisegmentectomy with caudate lobectomy. J Surg Oncol 2007; 96 (5) 438-441
  CrossrefPubMedGoogle Scholar
• 33 Kodama Y, Shimizu T, Endo H, Miyamoto N, Miyasaka K. Complications of percutaneous transhepatic portal vein embolization. J Vasc Interv Radiol 2002; 13 (12) 1233-1237
  CrossrefPubMedGoogle Scholar
• 34 Denys A, Bize P, Demartines N, Deschamps F, De Baere T ; Cardiovascular and Interventional Radiological Society of Europe. Quality improvement for portal vein embolization. Cardiovasc Intervent Radiol 2010; 33 (3) 452-456
  CrossrefPubMedGoogle Scholar
• 35 Di Stefano DR, de Baere T, Denys A , et al. Preoperative percutaneous portal vein embolization: evaluation of adverse events in 188 patients. Radiology 2005; 234 (2) 625-630
  CrossrefPubMedGoogle Scholar
• 36 Madoff DC, Hicks ME, Vauthey JN , et al. Transhepatic portal vein embolization: anatomy, indications, and technical considerations. Radiographics 2002; 22 (5) 1063-1076
  PubMedGoogle Scholar
• 37 Azoulay D, Castaing D, Krissat J , et al. Percutaneous portal vein embolization increases the feasibility and safety of major liver resection for hepatocellular carcinoma in injured liver. Ann Surg 2000; 232 (5) 665-672
  CrossrefPubMedGoogle Scholar
• 38 Palavecino M, Chun YS, Madoff DC , et al. Major hepatic resection for hepatocellular carcinoma with or without portal vein embolization: perioperative outcome and survival. Surgery 2009; 145 (4) 399-405
  CrossrefPubMedGoogle Scholar
• 39 Lewandowski RJ, Geschwind JF, Liapi E, Salem R. Transcatheter intraarterial therapies: rationale and overview. Radiology 2011; 259 (3) 641-657
  CrossrefPubMedGoogle Scholar
• 40 Kollmar O, Corsten M, Scheuer C, Vollmar B, Schilling MK, Menger MD. Portal branch ligation induces a hepatic arterial buffer response, microvascular remodeling, normoxygenation, and cell proliferation in portal blood-deprived liver tissue. Am J Physiol Gastrointest Liver Physiol 2007; 292 (6) G1534-G1542
  CrossrefPubMedGoogle Scholar
• 41 Luo MY, Shan H, Jiang ZB, Liang WW, Zhang JS, Li LF. Capability of multidetector CT to diagnose hepatocellular carcinoma-associated arterioportal shunt. World J Gastroenterol 2005; 11 (17) 2666-2669
  PubMedGoogle Scholar
• 42 Ogata S, Belghiti J, Farges O, Varma D, Sibert A, Vilgrain V. Sequential arterial and portal vein embolizations before right hepatectomy in patients with cirrhosis and hepatocellular carcinoma. Br J Surg 2006; 93 (9) 1091-1098
  CrossrefPubMedGoogle Scholar
• 43 Yoo H, Kim JH, Ko GY , et al. Sequential transcatheter arterial chemoembolization and portal vein embolization versus portal vein embolization only before major hepatectomy for patients with hepatocellular carcinoma. Ann Surg Oncol 2011; 18 (5) 1251-1257
  CrossrefPubMedGoogle Scholar
• 44 Narita M, Oussoultzoglou E, Jaeck D , et al. Two-stage hepatectomy for multiple bilobar colorectal liver metastases. Br J Surg 2011; 98 (10) 1463-1475
  CrossrefPubMedGoogle Scholar
• 45 Brouquet A, Abdalla EK, Kopetz S, Garrett CR, Overman MJ, Eng C , et al. High survival rate after two-stage resection of advanced colorectal liver metastases: response-based selection and complete resection define outcome. J Clin Oncol 2011; 29 (8) 1083-1090
  CrossrefPubMedGoogle Scholar
• 46 Roskams TA, Libbrecht L, Desmet VJ. Progenitor cells in diseased human liver. Semin Liver Dis 2003; 23 (4) 385-396
  Article in Thieme ConnectPubMedGoogle Scholar
• 47 Theise ND, Nimmakayalu M, Gardner R , et al. Liver from bone marrow in humans. Hepatology 2000; 32 (1) 11-16
  CrossrefPubMedGoogle Scholar
• 48 Körbling M, Katz RL, Khanna A , et al. Hepatocytes and epithelial cells of donor origin in recipients of peripheral-blood stem cells. N Engl J Med 2002; 346 (10) 738-746
  CrossrefPubMedGoogle Scholar
• 49 am Esch JS, Schmelzle M, Fürst G , et al. Infusion of CD133  bone marrow-derived stem cells after selective portal vein embolization enhances functional hepatic reserves after extended right hepatectomy: a retrospective single-center study. Ann Surg 2012; 255 (1) 79-85
  CrossrefPubMedGoogle Scholar
• 50 Avritscher R, Duke E, Madoff DC. Portal vein embolization: rationale, outcomes, controversies and future directions. Expert Rev Gastroenterol Hepatol 2010; 4 (4) 489-501
  CrossrefPubMedGoogle Scholar
• 51 Madoff DC, Gupta S, Pillsbury EP , et al. Transarterial versus transhepatic portal vein embolization to induce selective hepatic hypertrophy: a comparative study in swine. J Vasc Interv Radiol 2007; 18 (1 Pt 1) 79-93
  CrossrefPubMedGoogle Scholar