Portal vein embolization

Surgery to remove part of the liver, called a liver resection or hepatectomy, is often the best chance to cure liver tumors. These can be cancers that start in the liver or cancers that have spread there, for example from the colon. The liver can regrow after surgery, but only if enough healthy liver is left behind to keep you well in the meantime.

The part of the liver that will stay after surgery is called the future liver remnant. Surgeons usually want it to be at least about 20 to 25 percent of your total liver if the liver is healthy, about 30 percent if it has been affected by chemotherapy or fatty liver, and about 40 percent if there is scarring (cirrhosis). If the remnant is too small, there is a higher risk of liver failure after surgery.

The liver has two blood supplies. The portal vein brings about three quarters of its blood from the intestines, and the hepatic artery brings the rest. In portal vein embolization (PVE), an interventional radiologist, a doctor who uses imaging to guide needles and thin tubes, blocks the portal vein branches going to the part of the liver that will be removed. Blood is redirected to the part that will stay, which responds by growing, usually over a few weeks.

PVE is planned together with your liver surgeon and oncologist. It is usually recommended after a CT or MRI scan shows that the future liver remnant is too small for a safe operation.

Before PVE, I sit down with the CT or MRI and measure the liver segment by segment, so I know exactly how much will remain and how much it needs to grow. I also look closely at the portal vein branches, because every liver is wired a little differently. I tell patients that this is a step toward surgery, not the treatment itself, and I work closely with their surgeon on the timing.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos

PVE is the most established way to grow the liver before surgery. Depending on your situation, your team may also consider other strategies.

For some tumors, radiation delivered through the arteries, called Y-90 radioembolization, can both treat the tumor and help the rest of the liver grow over a longer time. Your team will explain which approach fits your case.

PVE is done at El Camino Hospital. When you arrive, a nurse helps you change into a gown, checks your vital signs, starts an IV and gives you fluids and medicines, which may include an antibiotic and an anti-nausea medicine.

1. 1
   Getting comfortable

   You lie on the procedure table and are connected to heart, blood pressure and oxygen monitors. You receive moderate sedation through your IV so you are relaxed and drowsy. The skin on your right side or upper belly is cleaned and numbed, which stings for a few seconds.

2. 2
   Reaching the portal vein

   Using ultrasound, the doctor guides a thin needle through the skin into a branch of the portal vein inside the liver. A thin catheter is then passed in, and contrast dye shows the portal vein branches on X-ray and measures the pressure inside them.

3. 3
   Embolization

   Tiny particles, and often small metal coils or a medical glue, are placed in the branches going to the part of the liver that will be removed. You may feel some pressure or ache in the right upper belly or shoulder.

4. 4
   Closing the track

   As the catheter is removed, the small track through the liver is sealed with a plug or coils to lower the risk of bleeding. A small bandage covers the skin. The procedure usually takes 1 to 2 hours.

On the portal venogram, the portal vein branches look like a tree spreading through the liver. After embolization, the branches to the part being removed no longer fill with contrast, while those to the part that will stay are fuller.

Afterward you rest in the recovery area for a few hours while the nurses check your vital signs and the puncture site. You can eat, drink and see your family. Many people go home the same day; some stay one night for observation and pain control.

1. Day of the procedure
   Rest. No driving, alcohol or important decisions for the rest of the day. You may shower tonight, but do not soak the site in a bath or pool for 1 week.
2. First week
   Take it easy. Dull ache in the right upper belly, pain in the right shoulder, mild fever, nausea and tiredness are common. No heavy lifting, exercise or strenuous activity for 7 days. You can drive the day after, if you are not taking strong pain medicine.
3. 7 to 10 days
   Most people feel back to normal.
4. About 2 weeks
   Follow-up visit to check how you are recovering.
5. 3 to 6 weeks
   A CT or MRI measures how much the future liver remnant has grown. If it is large enough, surgery is scheduled.

In published studies, the future liver remnant usually grows by about 30 to 40 percent of its original size within 3 to 6 weeks, and most people who have PVE go on to surgery. In some people, roughly 1 in 10 to 1 in 5, the liver does not grow enough or the cancer grows during the wait, and surgery is not possible. Your team will keep you informed at each step.