Portal vein embolization

Case contributed by Dr Matt A. Morgan

Presentation

Patient with hepatitis B and a resectable right lobe hepatocellular carcinoma. No cirrhosis or portal hypertension.

Patient Data

Age: 60 years
Gender: Male
dsa

Sequence of a portal vein embolization with n-butyl cyanoacrylate (NBCA). Approach through the right hepatic lobe.

Initial portal vein run, showing opacification of predominantly the right portal venous system. The left portal vein opacifies, but the distal branches are not yet filled. Portal pressures are taken to exclude portal hypertension.

Transcatheter instillation of n-butyl cyanoacrylate (NBCA).

Continued transcatheter instillation of n-butyl cyanoacrylate (NBCA). The patchy filling defects in the portal vein correspond to the occlusive material.

Finish run of the portal vein. Note how the distal right portal vein branches are no longer opacified and are instead filled with the embolization material. Contrast is routed into the left portal venous system.

Case Discussion

Portal vein embolization (PVE) is a technique used by interventional radiologists to improve the postoperative outcome of a hepatectomy.

When a part of the liver is resected, the remaining component is referred to as the future liver remnant (FLR). If this remnant liver were too small to supply the patient's body size, then the postoperative prognosis would be poor. PVE can "grow" the FLR by preoperatively occluding the lobe to be resected (almost always the right lobe). Increased blood flow to the left hepatic lobe, and serum factors released by the injured occluded liver, induce hyperplasia in the left hepatic lobe.

PVE is a relatively safe procedure, with postprocedure mortality reported at 0% and morbidity at 2.2% 1.

Portal hypertension is a major contraindication to PVE, since it will drive up portal pressures even further, possibly resulting variceal hemorrhage.

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