Review Article
Portal Vein Embolization in Preparation for Major Hepatic Resection: Evolution of a New Standard of Care

https://doi.org/10.1097/01.RVI.0000159543.28222.73Get rights and content

Portal vein (PV) embolization (PVE) is gaining acceptance in the preoperative management of patients selected for major hepatic resection. PVE redirects portal blood flow to the intended liver remnant to induce hypertrophy of the nondiseased portion of the liver and thereby reduce complications and shorten hospital stays after resection. This article reviews the rationale and existing literature on PVE, including the mechanisms of liver regeneration, the pathophysiology of PVE, the imaging techniques used to measure liver volumes and estimate functional hepatic reserve, and the technical aspects of PVE, including approaches and embolic agents used. In addition, the indications and contraindications for performing PVE in patients with and without chronic liver disease and the multidisciplinary approach required for the treatment of these complex cases are emphasized.

Section snippets

MECHANISMS AND RATES OF LIVER REGENERATION

The ability of the liver to regenerate after injury or resection is the basis for preparation for major hepatectomy in a patient with an anticipated small liver remnant. Despite its considerable metabolic load, the liver is essentially a quiescent organ in terms of hepatocyte replication, with only 0.0012%– 0.01% of hepatocytes undergoing mitosis at any time (20, 21, 22). However, this low cell turnover in the healthy liver can be altered by toxic injury or surgical resection, which stimulates

CLINICAL RATIONALE FOR PVE BEFORE MAJOR LIVER RESECTION

Makuuchi and colleagues (10) published the initial experience with preoperative PVE to induce left liver hypertrophy preceding right hepatectomy. Their rationale for the use of PVE in this setting was to (i) minimize the abrupt increase in portal pressure at resection that can lead to hepatocellular damage to the FLR, (ii) dissociate portal pressure–induced hepatocellular damage from direct trauma to the FLR during physical manipulation of the liver at the time of surgery (together, these forms

MEASUREMENT OF FLR VOLUME AND PREDICTING FUNCTION AFTER PVE

Computed tomography (CT) with volumetry is essential for planning hepatic resection (16, 39, 40). Three-dimensional CT volumetric measurements are acquired by outlining the hepatic segmental contours and calculating the volumes from the surface measurements from each slice (Fig 1). CT must be performed with intravenous contrast agent administration in several phases to demarcate the vascular landmarks of the hepatic segments. With this technique, the total liver volume and FLR volume can be

PVE Approaches

PVE is performed to redirect portal blood flow toward the hepatic segments that will remain after surgery (ie, the FLR). To ensure adequate hypertrophy, embolization of portal branches must be as complete as possible so that recanalization of the occluded portal system is minimized. The entire portal tree to be resected must be occluded to avoid the development of intrahepatic portoportal collaterals that may limit regeneration (44).

PVE can be performed by any of three standard approaches: the

Indications

To determine whether a patient will benefit from PVE, a sequence of factors must be considered by the surgeon treating the patient. First, the presence or absence of underlying liver disease will have a major impact on the volume of liver remnant needed for adequate function. Second, patient size must be considered—large patients require larger liver remnants, smaller patients require smaller liver remnants. Third, the extent and complexity of the planned resection and the probability that

Chronic Liver Disease

In patients with chronic liver disease (chronic hepatitis, fibrosis, or cirrhosis), the increase in nonembolized liver volumes after PVE varies (range, 28%–46%), and hypertrophy after PVE may take more than 4 weeks because of slower regeneration rates (24, 32). The degree of parenchymal fibrosis is thought to limit regeneration, possibly as a result of reduced portal blood flow (59). The complication rates after PVE are higher in patients with chronic liver disease than in those with an

CONCLUSIONS

PVE is a validated technique to increase the volume and function of the liver remnant before resection of liver tumors. The technique increases the safety of major resection in patients with liver disease and extends the option of resection to patients with multiple hepatic metastases and limited parenchymal sparing from metastatic disease. Careful attention to critical factors such as the presence or absence of underlying liver disease, adjustment of liver size to patient size according to

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