Sequential Preoperative Ipsilateral Hepatic Vein Embolization After Portal Vein Embolization to Induce Further Liver Regeneration in Patients With Hepatobiliary Malignancy

Objective: To assess the effect of ipsilateral hepatic vein embolization (HVE) performed after portal vein embolization (PVE) on liver regeneration. Summary Background Data: PVE induces shrinkage of the embolized lobe and compensatory enlargement of the non-embolized lobe, but it does not always induce sufficient liver regeneration. There was no effective method to accelerate liver regeneration in addition to PVE yet. Methods: During a 1-year study period, preoperative HVE were performed on 12 patients who had shown limited liver regeneration after PVE awaiting right hepatectomy. The right hepatic vein was embolized with multiple coils after insertion of vena cava filters or vascular plugs. Results: No HVE procedure-related complications occurred, but embolization of the wrong hepatic vein trunk occurred in I patient. The increase in blood liver enzymes after HVE was comparable with that after PVE alone. In 9 patients who underwent hepatectomy, the proportions of future liver remnant volume to total liver volume were 34.8% 1.5% before PVE, 39.7% +/- 0.6% 1 to 2 weeks after PVE, 44.2% +/- 1.1% 2 weeks after HVE, and 64.5% +/- 6.2% 1 week after right hepatectomy. Cirrhotic livers showed lower regeneration rates following HVE after PVE and I patient underwent hepatectomy 17 months after HVE. Immunohistochemistry showed that apoptosis occurred more in the liver area affected by both PVE and HVE than in that affected by PVE alone. Conclusions: Preoperative sequential application of PVE and HVE seems to be safe and effective in facilitating contralateral liver regeneration by inducing more severe liver damage than PVE alone.