Research Article
Letters
July 2006

Portal Vein Embolization: A Plea for Strict Patient Selection

In the December 2005 issue of the AJR, Dr. Covey and colleagues [1] reported their experience with performing portal vein embolization (PVE) using polyvinyl alcohol particles in 58 patients. We believe that some points of critical clinical importance should be highlighted.
First, the patient selection for this technique is not precisely described in the Materials and Methods section and appears unusual in terms of volume of the future remnant liver (FRL). The surgical literature has not shown any difference in terms of postoperative morbidity when the FRL is above 30-35% of the total liver volume estimated by a formula or measured by CT. In the article of Covey et al. [1], the ratio between the FRL and the total liver volume measured using CT was 39%, 31%, and even 64% for patients who ultimately underwent, respectively, right portal vein, right portal vein and segment IV, or left portal vein embolization. Do the authors think that a patient with a resection of 36% of a noncirrhotic liver requires a PVE that ultimately increases the FRL by 1.5%? Moreover, CT volumetry results obtained before and after PVE are missing in eight of the 58 patients, making the PVE or the surgical decision difficult to take and the benefit of PVE nonassessable.
The method of measurement of the FLR ratio (FLR/total liver volume) did not take into consideration the volume of the tumor. Because the tumor cannot be considered as functional liver, it is usually subtracted from the total liver volume. For example, the patient with the 12-cm tumor had about 850 cm3 of tumor that is not functional parenchyma; however, Covey et al. considered that as functional liver in their calculation.
Moreover, it has not, to our knowledge, been shown that a liver that has received chemotherapy carries a higher risk of postoperative failure; contrary to what is discussed on page 1625 [1], there is some evidence that hypertrophy of the postchemotherapy liver after PVE is equivalent to a liver that did not receive chemotherapy [2]. Indeed, we found that in six patients who underwent even intraarterial hepatic chemotherapy, the rate of hypertrophy was equivalent to that of other patients. It would have been interesting in that prospect to review the pathologic specimen from the hepatectomy to evaluate the parenchymal changes induced by chemotherapy and justify their indications.
Finally, we would like to underline that even if cyanoacrylate can be mixed with tantalum powder, as written on page 1623 [1], that technique has not been used in any reports of PVE, to our knowledge. Cyanoacrylate is typically mixed with iodized oil (Lipiodol, Guerbet). Indeed, we warn readers about the use of Lipiodol and tantalum powder, the combination of which will induce immediate polymerization and a too-proximal obstruction with a risk of gluing the catheter tip.
PVE is a complex procedure with potential complications [3, 4] regardless of which embolic materials are used. We strongly think that this technique should be limited to accepted indications and should not be extended to situations in which it has never been proven of any benefit.

References

1.
Covey AM, Tuorto S, Brody LA, et al. Safety and efficacy of preoperative portal vein embolization with polyvinyl alcohol in 58 patients with liver metastases. AJR 2005; 185:1620-1626
2.
De Baere T, Roche A, Elias D, Lasser P, Lagrange C, Bousson V. Preoperative portal vein embolization for extension of hepatectomy indications. Hepatology 1996; 24:1386-1391
3.
Di Stefano DR, de Baere T, Denys A, et al. Preoperative percutaneous portal vein embolization: evaluation of adverse events in 188 patients. Radiology 2005; 234:625-630
4.
Madoff DC, Abdalla EK, Vauthey JN. Portal vein embolization in preparation for major hepatic resection: evolution of a new standard of care. J Vasc Interv Radiol 2005; 16:779-790

Information & Authors

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Published In

American Journal of Roentgenology
Pages: W125
PubMed: 16794127

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Affiliations

Centre Hospitalo-Universitaire Vaudois 1011 Lausanne, Switzerland
Institut Gustave Roussy Desmoulins, 94805 Villejuif, France
Centre Hospitalo-Universitaire Vaudois 1011 Lausanne, Switzerland

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