Bize, Pierre

De Baere, Thierry

Demartines, Nicolas

Denys, Alban

Deschamps, Frederic

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CIRSE GUIDELINESQuality Improvement for Portal Vein EmbolizationAlban Denys • Pierre Bize • Nicolas Demartines •Frederic Deschamps • Thierry De BaereReceived: 5 October 2009 / Accepted: 5 October 2009 / Published online: 4 February 2010 Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2010IntroductionMajor hepatectomy carries a significant risk of mortality. Inpatients with normal liver bearing metastases, mortalityafter major hepatectomy ranges from 0.5% to 4%, but inpatients [1] with chronic liver disease, such as cholestaticor cirrhotic liver, mortality increases to 4% to 12% [2, 3].The main cause of mortality as well as postoperativemorbidity after major hepatic resection is liver insuffi-ciency, often due to an insufficient liver remnant volume[4, 5]. It has been demonstrated from animal experimentsand clinical data that redirection of the portal flow toward apart of the liver will induce hypertrophy of this part. Thisredirection of portal flow can be obtained by surgicalligation or by percutaneous embolization (PVE). Today,PVE is preferred to surgical ligation to avoid additionalsurgery. However, when surgery is performed, usually forresection of the primary tumor, and portal vein flowredistribution is required, no clear recommendations can begiven regarding whether it is preferable to carry out per-cutaneous PVE in a second step or ligation at the time ofsurgery. Some studies have reported greater hypertrophyafter PVE [6], whereas others have reported no differencesin hypertrophy [7]. The aim of PVE is to (1) preoperativelyincrease the volume of the future liver remnant to enablesurgery and (2) to decrease postoperative morbidity whenthe only contraindication to surgery is an initially insuffi-cient remnant liver.DefinitionsFuture liver remnant (FLR) is the liver that will be left inplace after surgery and that was not targeted by emboliza-tion. The FLR must hypertrophy after portal vein emboli-zation (PVE). Most teams wait 4 weeks before surgery.FLR hypertrophy must be measured by way of computedaxial tomography (CAT) examination after injection ofiodine with volumetric measurements of the FLR segments,with the results compared with the measurements per-formed before PVE using the same technique.Hypertrophy can be quantified as FLR hypertrophy,which is defined as the difference between FLR after awaiting period from 3 to 6 weeks after PVE minus FLRbefore PVE divided by FLR before PVE. The waiting periodmust be long enough to allow hypertrophy and as short aspossible to avoid tumor growth, which precludes surgery.Hypertrophy can also be quantified by increased FLR ratio.The FLR ratio is defined as (FLR volume—tumor in theFLR)/(total liver volume—total tumor volume) [8].Technical success of PVE is defined by a completeocclusion of portal branches feeding the future resectedliver segments. Branches of the FLR must be patent withhepatopetal flow. In the late phase of control portography,parenchymography must be visible only in the FLR.Clinical success is considered to occur when the patientreaches the volumetric criteria for liver resection.A. Denys (&)  P. BizeDepartment of Radiology and Interventional Radiology,Centre Hospitalier Universitaire Vaudois, Universityof Lausanne, 1011 Lausanne, Switzerlande-mail: albandenys@orange.fr; Alban.Denys@chuv.chN. DemartinesDepartment of Visceral Surgery, Centre HospitalierUniversitaire Vaudois, University of Lausanne,1011 Lausanne, SwitzerlandF. Deschamps  T. De BaereDepartment of Interventional Radiology,Institut Gustave Roussy, Villejuif, France123Cardiovasc Intervent Radiol (2010) 33:452–456DOI 10.1007/s00270-009-9737-xMajor hepatic resection (or major hepatectomy) isdefined as a resection of at least four of eight segments ofthe liver. Right hepatectomy is defined as a resection ofsegments V to VIII. Extended right hepatectomy addi-tionally includes segment IV.Resection rate is defined as the number of embolizedpatients that will ultimately be resected.Materials and MethodsPatient SelectionPatients must be candidates for major hepatectomy or majorhepatectomy associated with radiofrequency ablation on theFLR. This decision should be made in the context of a tumorboard meeting that includes surgeons, hepatologists, on-cologists, and interventional radiologists. The only contra-indication to liver resection must be the initially insufficientvolume of the FLR. PVE indication is determined by theliver volumetry obtained from liver CAT [9].Liver volumetry is calculated manually from CAT slicesafter injection of contrast media, preferably in the portal orequilibrium phase to opacify all of the portal and hepaticveins. Slice thickness B5 mm is recommended. The FLR isdetermined according to the future resection plane in col-laboration with the surgical team. If radiofrequency abla-tion (RFA) is planned on a tumor in the FLR, the expectedvolume of RFA must be taken into consideration andsubtracted from the FLR volume. Tumor tissue must not betaken into consideration for volumetric evaluation becausevolumetry must evaluate liver tissue only.Blood tests—including liver enzyme, bilirubin level,partial thromboplastin time, prothrombin time (PT), andplatelet count must be obtained before PVE. Criteria topropose PVE are different according to the liver status andto the tumor involvement as follows:Patients with Tumors that Developed in NormalUnderlying Liver ParenchymaPVE is recommended when the FRL-to-total liver ratio is\25 to 30 [7, 10, 11]. The indication of PVE can beextended to a 40% FLR ratio in patients having receivedchemotherapy or showing abnormal indocyanine green testresults (or other abnormal liver function tests) [10, 12, 13].Patients with Tumors that Develop in Chronic LiverDisease and Cirrhosis StatesIn such cases, the decision is based either on liver volumeor on liver volume plus estimation of overall liver functionby indocyanin green retention rate at 15 min (ICCG 15).An FRLR of 40% is recommended when the ICCG 15 isbetween 10% and 20%. When the ICCG 15 is [20%, anFRLR of 50% is recommended [12–14].Patients with Tumors Invading the Biliary Tree Associatedwith CholestasisBecause biliary obstruction has impaired liver regenerationand hypertrophy, the biliary tree of the FRL must bedrained first, and PVE can be performed secondarily. Theindication is an FRLR \40% [15].Contraindication for PVE [11]PVE is contraindicated in the following types of patients:1. Tumors invading the portal vein(a) Portal hypertension (blocked to free hepatic veinpressure gradient [12 mmHg)2. Coagulation disorders (PT \ 60%, platelet count \50G/l)(a) Even if previous transarterial chemoembolization(TACE) may improve PVE results [16], a min-imum of 3-week delay between TACE and PVEis recommended.Patient Information to be Given Before TreatmentPatients should be informed that this procedure is not anantitumoral treatment but a treatment made to increasesafety or to enable a surgical procedure. Minor complica-tions are encountered in 20% to 25% of cases and aremainly associated with slight fever and abdominal dis-comfort and pain. Major complications are infrequent andmainly include infection and subcapsular hematoma,hemobilia, and portal vein thrombosis (\2% of cases).Mortality due to PVE has not been reported.When tumors (usually small nodules) are present in thenonembolized lobe, it must be explained to the patient thatthose lesions might increase in size more quickly due toPVE [17]. Patients must also be told that the efficacy of theprocedure can be estimated approximately 4 weeks afterPVE by way of CAT with injection of contrast media andliver volumetry.Embolization MethodAccess to the portal system should be done under ultra-sound guidance to puncture a peripheral branch [8]. Accesscan be obtained by way of controlateral approach (i.e.,puncture of the left portal branch and embolization of theA. Denys et al.: Quality Improvement for PVE 453123right portal branches) or ispsilateral approach (puncture ofthe right portal branch to embolize right portal branches.The advantage of the controlateral approach is easiercatheterization, but there is a risk of damage to the FLR.Five-French materials (catheter or introductory sheath)are usually recommended. The catheter should be placed atthe splenomesenteric confluence to perform a portographyto visualize portal anatomy, including its variations, and tolocalize segment IV branches. Measurement of portalpressure is not routinely performed in patients with normalliver. In cirrhotic patients, measuring the portal and centralvenous pressures is useful to determine whether the patienthas a portostemic gradient [12 mmHg in, which case thepatient is at major risk of perisurgical complications [18,19]. These patients are not eligible for PVE.The aim of embolization is complete obstruction of thetargeted branches and redistribution of flow to the FLRbranches only. Final portography is mandatory to verifythis objective. A final pressure measurement should beobtained at the end of the procedure in patients withchronic liver disease to document portal pressure increase,which is usually approximately 3 mmHg. Embolization ofsegment IV branches is recommended in patients withtumors who are undergoing extended right hepatectomy.However, if embolization of that segment causes risk ofreflux into the portal branch of the FRL, such embolizationmust not be performed because any major reflux into FRLportal branches might preclude surgery.Various embolic materials have been used. Someproducts are not recommended due to reported recanali-zation or lower induced hypertrophy as follows:GelfoamGelfoam is associated with a high rate of portal vein recan-alization and seems less efficient than other products [8].Nonspherical Polyvinyl Alcohol ParticlesPolyvinyl alcohol particles (PVA) have been used but areless efficient than spherical particles [20].AlcoholDirect intraportal injection has been described. Althoughefficient, it is hard to control and has been associated withsignificant morbidity (liver necrosis, portal vein thrombo-sis) [21].Drug-Loadable EmbolsThese have not been reported in PVE and cannot berecommended.Recommended products [14, 20, 22] include thefollowing:Mixture of n-Butyl-cyanoacrylate and Iodized OilThis has been described extensively as showing goodresults and low morbidity. Usually a mixture of one part n-butyl-cyanoacrylate (NBCA) to one or to parts lipiodol isused. Injections of small aliquots in between abundantflushing with nonionic liquid, such as dextran or glucose5%, is the most commonly reported technique.Spherical MicroparticlesThese are associated with coil embolization, which ismostly described in North American reports, and have beenreported to be superior to nonspherical PVA. It seems asefficient as NBCA, although it has never been compared inrandomized trials. Most teams start with 300- to 500-lmparticles and finish with 700- to 900-lm particles. Coils areused at the end of the procedure to allow for completeocclusion of the proximal trunk. It is advisable to avoid alltoo proximal occlusions and rather leave 1 cm unembol-ized segment of the right portal branch to facilitate surgicalligation at the time of liver resection.Association of Fibrin Glue with Iodized OilThis has mostly been described in Japan and has thedrawback of requiring special catheters that are onlyavailable in Asia.Medication and Periprocedural CurePVE can be carried out as an outpatient procedure whenconscious sedation is used. A 1- or 2-day hospital stay isrecommended, as reported by most teams using eitherconscious sedation associated with local anesthesia orgeneral anesthesia.There is no consensus on the use of antibiotics, and thetype of antibiotics and the length of treatment vary fromone report to another [11], except in patients with anassociated biliary procedure. Because little to no liver tis-sue necrosis is found after PVE if an antibiotic is given, itmust be administered for a very short period of time, froma single dose to 48 h. Mild to moderate abdominal painafter PVE has been reported in 20% to 30% of patients andis usually easily controlled by oral analgesia. Use of purealcohol as embolic material is associated with more severeabdominal pain.Biologic tests are not mandatory after the procedure.Slightly increased aspartate aminotransferase and alanineaminotransferase levels with a peak at day 3 after the454 A. Denys et al.: Quality Improvement for PVE123procedure have been reported, but these are without clini-cal significance.Results [14]The technical success rate should be close to 100%. Fewcases of failures or repeated procedures have been reportedin the literature. The resection rate should be approxi-mately 85%. This rate may decrease to 70% in the case ofcirrhotic patients. Reasons for nonresection are tumorprogression, peritoneal metastases, or unsuspected metas-tases discovered at laparotomy. Absence of hypertrophy israre, \10% in metastatic liver, but it can reach 20% incirrhotic patients.In patients with normal liver and liver metastases, theincrease of the FLR ratio is between 8% and 25%, andregeneration is always observed after PVE. In cirrhoticpatients, PVE fails to induce left-lobe hypertrophy in 20%of cases. Increased rate of FLR ratio in this population isslightly lower, between 6% and 20%.Recent studies have demonstrated that hypertrophy isinversely proportional to the FRL ratio before PVE,meaning that the smaller FRL before PVE will have thelarger hypertrophy. Consequently there is no lower limitfor the FRL ratio to perform PVE.Complications [14, 23]In terms of complications (Table 1), a rate of minor com-plications (20% to 25%) is considered acceptable. Withmajor complications, this rate should be \5% and shouldnot preclude further liver resection. Except for inadvertentembolization, most complications will occur in the punc-tured lobe, which is an argument in favour of a homolateralapproach. However, complication rates for homolateral andcontrolateral approaches are the same. Reported in theliterature as the only factor increasing complications ispuncture of the posterior segment versus puncture of theanterior segment [24], thus advocating puncture of theanterior segment when compatible with the location of thePVE to be performed.References1. Nordlinger B, Peschaud F, Malafosse R (2003) Resection of livermetastases from colorectal cancer—how can we improve results?Colorectal Dis 5:515–5172. Farges O, Belghiti J, Kianmanesh R et al (2003) Portal veinembolization before right hepatectomy: prospective clinical trial.Ann Surg 237:208–2173. Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH (1999)Clinical score for predicting recurrence after hepatic resection formetastatic colorectal cancer: analysis of 1001 consecutive cases.Ann Surg 230:309–3184. Abdalla EK, Barnett CC, Doherty D, Curley SA, Vauthey JN(2002) Extended hepatectomy in patients with hepatobiliarymalignancies with and without preoperative portal vein emboli-zation. Arch Surg 137:675–6805. Yigitler C, Farges O, Kianmanesh R, Regimbeau JM, Abdalla EK,Belghiti J (2003) The small remnant liver after major liver resec-tion: how common and how relevant? Liver Transpl 9(9):S18–256. Broering DC, Hillert C, Krupski G et al (2002) Portal veinembolization vs. portal vein ligation for induction of hypertrophyof the future liver remnant. J Gastrointest Surg 6:905–9137. Capussotti L, Muratore A, Baracchi F et al (2008) Portal veinligation as an efficient method of increasing the future liverremnant volume in the surgical treatment of colorectal metasta-ses. 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Madoff DC, Abdalla EK, Gupta S et al (2005) Transhepaticipsilateral right portal vein embolization extended to segment IV:improving hypertrophy and resection outcomes with sphericalparticles and coils. J Vasc Interv Radiol 16(2 Pt 1):215–22521. Shimamura T, Nakajima Y, Une Y et al (1997) Efficacy andsafety of preoperative percutaneous transhepatic portal emboli-zation with absolute ethanol: a clinical study. Surgery 121:135–14122. de Baere T, Denys A, Paradis V (2009) Comparison of fourembolic materials for portal vein embolization: Experimentalstudy in pigs. Eur Radiol [Epub ahead of print]23. Di Stefano DR, de Baere T, Denys A et al (2005) Preoperativepercutaneous portal vein embolization: evaluation of adverseevents in 188 patients. Radiology 234:625–63024. Kodama Y, Shimizu T, Endo H, Miyamoto N, Miyasaka K(2002) Complications of percutaneous transhepatic portal veinembolization. J Vasc Interv Radiol 13:1233–1237456 A. Denys et al.: Quality Improvement for PVE123

Quality Improvement for Portal Vein Embolization

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Quality Improvement for Portal Vein Embolization

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