Safety and Efficacy of portal vein embolization after hepatic arterial infusion pump placement

Hepatic arterial infusion (HAI) combined with systemic chemotherapy is used to treat patients with advanced liver cancers in a staged operative approach. At the time of HAI pump placement, upwards of 60% of patients require ligation of aberrant hepatic arteries. We sought to characterize the safety and efficacy of portal vein embolization (PVE) for inducing liver hypertrophy in patients who underwent HAI with and without hepatic arterial ligation.

Materials and Methods:

An IRB approved retrospective review was conducted on all patients who underwent PVE between the years of 2015 and 2022, with and without preceding or subsequent HAI. Segmental liver volumes, the standardized future liver remnants (sFLR), percent volumetric changes, and the kinetic growth rates (KGR) were calculated using semi-automatic liver segmentation (IntelliSpace, Version 11.1, Philips Medical Systems, Netherlands) performed on multiphasic liver computed tomography scans prior to and 4-12 weeks after PVE. The impact of hepatic artery ligation was assessed by analyzing hepatic resection outcomes following PVE.

Results:

Between January 2015 and August 2022, 48 patients underwent technically successful PVE with 12 (25%) having a HAI pump as part of their operative clearance strategy. There were 9 HAI pumps (19%) placed before PVE and 3 (6%) after PVE. Among the 9 patients who underwent PVE after HAI, sFLR increased from 21.1 ± 6.8% (mean ± std) to 34.8 ± 6.0%, with KGR of 2.2 ± 1.8% (3 patients had KGRs below 2% but sFLR >30% prior to hepatectomy). Seven (78%) of these patients had hepatic artery ligation during HAI pump placement including 5 replaced right hepatic arteries and 5 accessory left hepatic arteries (4 patients required ligation of both). All patients with ligated right hepatic arteries developed robust intrahepatic left-to-right collateralization prior to PVE. Of these 9 patients, 5 (56%) proceeded to an extended right hepatectomy, 1 (11%) to a right hepatectomy. Three patients did not undergo hepatic resection due to interval development of extrahepatic disease. The median time from PVE to hepatic resection was 59 days. There were no biliary complications in the patients treated with PVE after HAI.

Conclusion:

PVE to induce liver hypertrophy in sequence with HAI for patients with advanced liver cancer was not associated with increased biliary complication or compromised hepatic function. HAI with or without prior hepatic arterial ligation should not be used to exclude patients from PVE.