PORTAL VEIN EMBOLIZATIONTOP 5 TIPS

William S Rilling MD, FSIR Professor of Radiology and Surgery

Vice Chair, Clinical OperationsDepartment of Radiology

Medical College of Wisconsin

CIO 2019

DISCLOSURES

• Research support : BTG, Siemens Healthcare, Sirtex

• Consultant : B Braun, BTG, BD/Bard, Terumo, Boston Scientific

PVE : TOP TIPS

• Patient selection• Imaging, volumes, timing, ? Y90

• Discuss segment 4• Embolization agents• Embolization technique

• Adjunctive methods

PATIENT SELECTION

• Test of time : trying to avoid PVE without resection

• Imaging : PET, MRI• Consider radiation lobectomy

PVE PATIENT SELECTION• 358 patients PVE

• Extrahepatic disease progression • Intrahepatic disease progression • Medical issues • Insufficient hypertrophy

• 282 patient to OR• 76 aborted resection in OR

• 118/358 ( 33%) do not go on to resection, outcomes not reported

Adapted from R Salem Shindoh et al. J Gastrointest Surgery 2014

RADIATION LOBECTOMY VS PVE

PVE : SEGMENT 4 ?

• More hypertrophy of FLR if segment 4 embolized

• Defining anatomy sometimes challenging

• Risk to FLR• Discuss with surgeon PRIOR to PVE

PVE EMBOLIZATION AGENTS

• Particles : PVA, spheres• Coils• Liquid agents : glue, onyx• combinations

PVE TECHNIQUE

• Ipsilateral portal v access• Neff set

• 5- 6 fr 25 cm sheath into RPV• Reverse curve catheter +/-

microcatheter• Segmental embolization

62 y.o. with ICC, ECOG 0

3:1 or 4:1 lipiodol: glue

baseline 6 weeks post PVE

ADJUNCTIVE TECHNIQUES

• Total venous deprivation• Right hepatic v embolized concurrently• Increases hypertrophy rate and FLR

volume

• Can also be used to salvage inadequate FLR hypertrophy

PVE SUMMARY

• Patient selection is key• Consider radiation lobectomy approach in

some patients

• Choose a consistent embolization agent• Discuss segment 4 on case by case

basis• Segmental approach