K.E.M. Radiology

Patients First!

Welcome to the Academic and Educational pages of the

Department of Radiology

Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India

Interventional Case Record

< Case 73 : August 2026 >

Preoperative portal vein embolization with coils to increase liver volume prior to right hepatectomy for hilar cholangiocarcinoma

Contributed by : Vismay Panchal

Other cases

Introduction:

Portal vein embolization (PVE) is an established preoperative intervention performed to induce hypertrophy of the future liver remnant (FLR) in patients undergoing major hepatectomy. By redirecting portal venous flow from liver segments planned for resection to the remnant liver, PVE promotes compensatory hypertrophy, thereby reducing the risk of post-hepatectomy liver failure (PHLF). It is particularly indicated when the anticipated FLR is inadequate for safe hepatic resection.[1, 2]

Various embolic agents, including polyvinyl alcohol (PVA) particles, coils, N-butyl cyanoacrylate (NBCA), ethanol, and vascular plugs, have been employed for PVE, with each offering distinct advantages and limitations. The use of multiple coils in combination with PVA particles allows secure occlusion of individual portal vein branches while minimizing the risk of recanalization and non-target embolization.[3, 4, 5, 6]

This report describes successful preoperative right portal vein embolization using multiple coils for individual right portal vein branches in a patient with hilar cholangiocarcinoma. The procedure resulted in significant FLR hypertrophy, enabling safe right hepatectomy and highlightes the feasibility and effectiveness of this embolization strategy.[7, 8, 9]

Case presentation

A 62-year-old man presented with progressive, painless jaundice, pruritus, and dark colored urine over a sixweek period. He reported significant unintentional weight loss of approximately 8 kg over the preceding three months. Physical examination revealed deep icterus and hepatomegaly. There was no history of chronic liver disease, alcohol abuse, or prior hepatobiliary surgery.

Initial Laboratory Findings-

• Total Bilirubin: 8.4 mg/dL (Normal: 0.2-1.2 mg/dL)

• Direct Bilirubin: 6.2 mg/dL

• Alkaline Phosphatase: 642 U/L (Normal: 44-147 U/L)

• Gamma-GT: 485 U/L (Normal: 10-71 U/L)

• ALT: 98 U/L (Normal: 7-56 U/L)

• AST: 112 U/L (Normal: 10-40 U/L)

• Albumin: 3.2 g/dL (Normal: 3.5-5.0 g/dL)

• INR: 1.3 (Normal: 0.9-1.1)

• CA 19-9: 7433 U/mL (Normal: <37 U/mL)

• CEA: 4.4 ng/mL (Normal: <5.0 ng/mL)

Imaging findings :

Contrast-enhanced CT of the abdomen and MRCP revealed a hilar mass measuring approximately 3.2 × 2.8 cm involving the confluence of the hepatic duct with extension into the right hepatic duct (Bismuth-Corlette Type IIIa). The mass demonstrated irregular wall thickening with upstream dilatation of both intrahepatic biliary radicals. The right intrahepatic ducts were markedly dilated, while the left intrahepatic ducts showed moderate dilatation. There was no evidence of distant metastasis, but encasement of the right portal vein was noted without complete occlusion. The portal vein and hepatic artery on the left side were patent.

Figure 1: CECT (A + P) (A - Axial section and B - Coronal section) showing hilar cholangiocarcinoma with invasion into the rigth biliary system. [Segmental antomy of liver and portal vein marked]

Volumetric Assessment:

Pre-procedure CT volumetry demonstrated:

• Total Estimated Liver Volume (TELV): 1,480 mL

• Right Liver Volume (Segments V-VIII): 980 mL

• Segment IV Volume: 113 mL

• Left Lateral Sector Volume (Seg II-III): 140 mL

• Future Liver Remnant (FLR) - Left Lateral Sector: 253 mL (17.1%)

Figure 2 Pre emobolization CT volumetry (Volume rendered technique -VRT) showing total liver volume approx 1480 cc.

Figure 3 : Pre emobolization CT volumetry (Volume rendered technique -VRT) showing left lobe volume approx 253 cc.

The FLR/TELV ratio of 17.1% was below the safe threshold of 30% for a major hepatectomy in a patient with biliary obstruction and anticipated right hepatectomy. This placed the patient at significant risk for post-hepatectomy liver failure (PHLF).

Pre-Operative Biliary Drainage:

Given the obstructive jaundice and planned major hepatectomy, percutaneous transhepatic biliary drainage (PTBD) of the right hepatic duct system was performed first to decompress biliary system. Over the subsequent 10 days, total bilirubin decreased from 8.4 mg/dL to 2.1 mg/dL, and the patient's general condition improved with resolution of pruritus.

Surgical Plan:

The multidisciplinary hepatobiliary tumor board recommended right hepatectomy (Segments V, VI, VII, VIII) and extrahepatic bile duct resection, given the Bismuth-Corlette Type IIIa extension. However, inadequate FLR volume necessitated pre-operative portal vein embolization (PVE) to induce compensatory hypertrophy of the left lateral sector prior to surgery.

Interventional technique:

Pre-operative portal vein embolization (PVE) to increase the functional future liver remnant (FLR) volume prior to extended right hepatectomy for hilar cholangiocarcinoma (Bismuth-Corlette Type IIIa).[3, 6]

Pre-Procedural Planning:

• Review of contrast-enhanced CT and MRCP for portal venous anatomy

• Assessment of portal vein patency and tumor vascular involvement

• Volumetric analysis confirming FLR/TELV ratio of 17.1%

• Laboratory parameters acceptable: INR 1.3, Platelets 185,000/μL

• Informed consent obtained after discussion of risks and benefits

• Prophylactic intravenous ceftriaxone 1g administered pre-procedure

Approach:

Percutaneous transhepatic ipsilateral approach (right portal vein). The procedure was performed under conscious sedation with local anesthesia in the interventional radiology suite with fluoroscopy and ultrasound guidance.

Step 1: Portal Vein Access

Under real-time ultrasound guidance, a 21-gauge Chiba needle was used to puncture a peripheral anterior branch of the right portal vein (Segment V). The needle trajectory was carefully planned to avoid traversing the tumor mass. A 0.018-inch guidewire was advanced through the needle, and a 4-French vascular sheath was placed.

Step 2: Portography

A 4 french cobra catheter was advanced through the sheath into the main portal vein. Digital subtraction portography was performed, which confirmed:

• Patent main portal vein and left portal vein

• Right portal vein branches supplying Segments V, VI, VII, VIII

• Segment IV branches arising from the left portal vein

• No portal vein thrombus or significant collaterals

Baseline portal pressure measured: 18 mmHg (normal range: 5-10 mmHg)

Step 3: Right Portal Vein Embolization

The right portal vein branches (Segments V, VI, VII, VIII) were then systematically embolized:

Anterior Division (Segments V & VIII):

• Selective catheterization of anterior division portal branches

• Distal embolization with PVA particle (300-500 and 500-700 μm) as flow diminished

• Near-stasis achieved in all anterior division branches

Posterior Division (Segments VI & VII):

• Selective catheterization of posterior division portal branches

• Similar particulate embolization technique employed

• Careful attention to avoid reflux into Segment IV or left portal system

Figure 4 : image showing deployment of coil along with PVA particle using 4F cobra catheter. Also note PTBD catheter in the right biliary system.

Proximal Occlusion:

• 0.035-inch pushable embolization coils (8mm × 70mm {n= 2} , 4mm x 70mm {n= 3} , 5 mm x 70mm {n= 2} and 6 mm x 140mm {n=1}) were placed at the origin of the right anterior and posterior portal vein branches

• An additional 0.035-inch coil (8mm × 140mm {n=2}) was placed at the main right portal vein trunk, preserving approximately 1.5 cm of patent right portal vein to facilitate surgical ligation.

Figure 5 : Post coiling portogram showing no obvious flow in right portal system with normal flow in left portal system with parenchymal enhancement of left lobe of liver.

Step 4 : Final Portography

Final portography through the working catheter confirmed:

• Complete occlusion of right portal vein branches (Segments V-VIII)

• Patent left portal vein with free flow to Segments II , III and IV

• No evidence of non-target embolization

• No portal vein thrombus

Final portal pressure: 22 mmHg (mild increase post-embolization, acceptable)

Step 5 : Tract Embolization

The catheter and sheath were removed. The access tract was embolized using Gelfoam slurry to prevent hemorrhage. The skin puncture site was closed with surgical glue.

Post-Procedure Care :

• Vital signs monitored for four hours

• Liver function tests obtained at 24 hours and 48 hours

• Pain managed with oral analgesics

• Patient discharged home on post-procedure day 1

• Prophylactic antibiotics continued for five days

Post-Procedure Course:

• Day 1: Mild right upper quadrant discomfort, afebrile

• ALT peaked at 156 U/L (Day 2), returned to baseline by Day 7

• AST peaked at 178 U/L (Day 2), returned to baseline by Day 7

• Bilirubin remained stable at 2.0-2.3 mg/dL

• No fever, cholangitis, or signs of portal vein thrombosis

Follow-up Volumetric Assessment

CT volumetry performed at 4 weeks post-PVE demonstrated:

• Total Estimated Liver Volume (TELV): 1643.8 mL

• Right Liver + Segment IV (Embolized): 1133 mL (68%) - Atrophy

• Left lobe (Seg II, III , IV): 510 mL (32%) - Hypertrophy

• Future Liver Remnant (FLR): 510 mL (32%)

Results:

• Absolute FLR growth: +257 mL (+ 102 % relative growth)

• Degree of Hypertrophy (DH): +12.3 percentage points

• Kinetic Growth Rate (KGR): 3.5 % per week

• FLR/TELV ratio improved from 17.1% to 32%

[Figure 6 with caption 6] [Figure 7 with caption 7]

Figure 6 : Four week follow up CT Volumetry (Volume rendered technique - VRT) - showing relative atrophy of right lobe of liver (Volume 1133 cc) with significant hypertrophy of left lobe of liver (volume 510 cc) . Note no Significant change in total liver volume ( Volume 1643 cc)

Figure 7 : Four week follow up CT Volumetry (Volume rendered technique - VRT) - showing significant hypertrophy of left lobe of liver (volume 510 cc).

Discussion

Hilar cholangiocarcinoma (HCCA) represents one of the most challenging hepatobiliary malignancies for surgical management. Complete surgical resection with negative margins (R0) remains the only potentially curative treatment, yet the surgical approach often requires extended hepatectomy with caudate lobectomy and extrahepatic bile duct resection.

The Bismuth-Corlette classification guides surgical planning: Type IIIa tumors involve the right hepatic duct, typically necessitating right hepatectomy or extended right hepatectomy.[8,9]

The liver's unique dual blood supply and remarkable regenerative capacity form the biological basis for PVE. By occluding the portal venous inflow to the liver segments planned for resection, PVE redirects portal blood flow to the future liver remnant (FLR), triggering compensatory hypertrophy through hepatocyte proliferation. This pre-operative augmentation of functional liver mass significantly reduces the risk of post-hepatectomy liver failure (PHLF), which remains the leading cause of mortality after major hepatectomy for HCCA.[10,11]]

Future Liver Remnant Volume Thresholds

The safety of major hepatectomy is critically dependent on adequate residual liver function. Current evidence supports a minimum FLR/TELV ratio of ≥30% for patients with normal underlying liver parenchyma undergoing major hepatectomy. [11,12]

However, for patients with hilar cholangiocarcinoma, the threshold is more stringent due to several factors:

1. Biliary obstruction impairs hepatocyte function and regenerative capacity

2. Preoperative cholangitis further compromises liver function

3. Extended resections (trisectionectomy) leave a smaller remnant

4. Portal vein resection may be required, adding surgical complexity

Studies have demonstrated that FLR volume < 30% is an independent predictor of postoperative hepatic insufficiency (OR 3.5) and liver failure-related death (OR 7.2). In the setting of biliary obstruction, many centers aim for an FLR/TELV ratio of ≥ 40% before proceeding with extended hepatectomy.[4,6,13,14,15]

Embolic Agent Selection:

The choice of embolic material significantly impacts procedural efficacy and

outcomes. The ideal embolic agent should:

• Produce permanent, complete vascular occlusion

• Be well tolerated by the patient

• Be technically simple to use

• Be cost-effective

In this case, a combination approach was utilized:

1. Polyvinyl Alcohol particles (300-700 μm): [3,12]

- Provide distal embolization of portal vein branches

- Prevent development of intrahepatic portoportal collaterals

- Biocompatible and well tolerated

2. Embolization Coils (0.018-inch and 0.035-inch): [3,7]

- Create a mechanical barrier against antegrade flow

- Allow preservation of a surgical cuff for intraoperative ligation

Recent evidence from the BEST-FLR randomized controlled trial and large retrospective series suggests that polyvinyl alcohol (PVA) with coils offer superior FLR hypertrophy compared to particles alone . PVA and Coils create permanent distal occlusion with shorter procedure times and lower radiation exposure. [12]

Ipsilateral vs. Contralateral Approach [3]

The percutaneous transhepatic approach to PVE can be performed via:

1. Ipsilateral Approach (through the liver to be resected): [3,7]

- Advantages: No puncture of the FLR; easier Segment IV embolization; access tract can be embolized

- Disadvantages: Technically challenging due to acute angles; risk of tumor seeding if traversing tumor

2. Contralateral Approach (through the FLR): [3]

- Advantages: Easier catheter manipulation; deployment of embolic material in direction of flow; better visualization

- Disadvantages: Risk of FLR injury; puncture tract cannot be embolized; complications affect the remnant liver.

In this case, the ipsilateral approach was selected to protect the FLR from any procedural injury. The anterior branch of the right portal vein was targeted to minimize the risk of tumor seeding. Reverse-curve catheters were available as backup if standard catheter shapes proved insufficient for right portal branch catheterization. [16]

Timing Considerations:

The optimal interval between PVE and surgery is typically four weeks, allowing sufficient time for compensatory hypertrophy while minimizing the risk of tumor progression. Studies in patients with hilar cholangiocarcinoma have shown that: [6,16]

• Liver regeneration occurs at 12-21 mL/day in normal livers. [16,17]

• Most hypertrophy is achieved within 2-4 weeks

• Longer intervals (>4 weeks) do not significantly increase FLR volume but may allow tumor progression

In patients requiring preoperative biliary drainage, the timing of PVE relative to drainage is important. Current evidence suggests that PVE should be performed as early as possible after adequate biliary decompression (bilirubin < 4 mg/dL), as prolonged intervals between drainage and surgery increase the risk of complications without improving outcomes. [5, 14]

Preoperative Biliary Drainage:

Preoperative biliary drainage is essential in hilar cholangiocarcinoma to:

• Resolve cholangitis and optimize liver function

• Allow accurate volumetric assessment of the FLR

• Improve nutritional status and coagulation profile

• Enable safe PVE by reducing portal venous inflammation

Endoscopic nasobiliary drainage (ENBD) of the future liver remnant is the preferred approach, as it provides effective decompression without the risk of stent occlusion. Unilateral drainage of the FLR is generally sufficient and reduces the risk of procedure-related cholangitis compared to bilateral drainage. [10,11]

Outcomes and Prognosis:

Portal vein embolization has significantly improved the safety of extended hepatectomy for hilar cholangiocarcinoma. Key outcomes include:

• Technical success rate: >95%

• Procedure-related mortality: ~0%

• Major complication rate: <5%

• Resection rate after PVE: 65-80%

• Postoperative mortality in resected patients: 4.5-12%

• 5-year survival after curative resection: 25-40%

The degree of hypertrophy (DH) and kinetic growth rate (KGR) are important predictors of postoperative outcomes. A DH ≥5% and KGR ≥2% per week are associated with lower rates of PHLF. Post-PVE FLR volume is also an independent predictor of overall survival. [17]

However, approximately 15-25% of patients who undergo PVE will not proceed to surgery due to:

• Disease progression (hepatic metastasis, vascular invasion)

• Insufficient FLR hypertrophy

• Development of contraindications (portal vein thrombosis, worsening liver function)

Alternative and Adjunctive Strategies:

Several strategies have been explored to enhance FLR hypertrophy:

1. Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS):

- Produces rapid, massive hypertrophy (median 80% increase in 7 days)

- However, associated with high morbidity (40-60%) and mortality (5-15%)

- Functional growth may not match volumetric growth

- Reserved for selected patients with insufficient hypertrophy after PVE

2. Hepatic Vein Embolization (HVE):

- Combined with PVE to further enhance FLR growth

- Still under investigation

3. Two-Stage Hepatectomy:

- For bilobar disease

- First stage: PVE + clearing of left lobe disease

- Second stage: Right hepatectomy after FLR hypertrophy

4. Liver Venous Deprivation (LVD):

- Simultaneous portal and hepatic vein embolization

- Emerging technique showing promise for faster hypertrophy

Conclusion:

Pre-operative portal vein embolization is a safe, effective and essential interventional radiological procedure that enables curative-intent hepatectomy for hilar cholangiocarcinoma in patients with inadequate future liver remnant. By redirecting portal venous flow to the FLR, PVE induces compensatory hypertrophy that significantly reduces the risk of post-hepatectomy liver failure.

Key points from this case:

1. Patient selection: PVE is indicated when the anticipated FLR/TELV ratio is < 30% (or < 40% in the setting of biliary obstruction) before major hepatectomy for hilar cholangiocarcinoma.

2. Preoperative Optimization: Adequate biliary drainage of the FLR should precede PVE, with serum bilirubin ideally < 4 mg/dL. This optimizes liver regenerative capacity and reduces procedural risks.

3. Technical Approach: The ipsilateral approach through the right portal vein protects the FLR from injury.

4. Embolic Strategy: A combination of particulate embolization (distal) and coil embolization (proximal) achieves complete, permanent portal venous occlusion.

5. Timing: Surgery should be scheduled 4-6 weeks after PVE, when adequate hypertrophy has been achieved but before significant tumor progression can occur.

6. Outcomes: In this case, PVE achieved increase in FLR volume, raising the FLR/TELV ratio from 17.1% to 32%, enabling safe right hepatectomy.

Interventional radiologists play a pivotal role in multidisciplinary management of hilar cholangiocarcinoma. PVE transforms patients who would otherwise be considered poor surgical candidates into individuals who can undergo potentially curative resection with acceptable perioperative risk.

References

1. Nagino M, Kanai M, Morioka A, et al. Portal and arterial embolization before extensive liver resection in patients with markedly poor functional reserve. J Vasc Interv Radiol. 2000;11(8):1063-1068.

2. Ribero D, Abdalla EK, Madoff DC, et al. Portal vein embolization before major hepatectomy and its effects on regeneration, resectability and outcome. Br J Surg. 2007;94(11):1386-1394.

3. Madoff DC, Hicks ME, Vauthey JN, et al. Transhepatic portal vein embolization: anatomy, indications, and technical considerations. Radiographics. 2002;22(5):1063-1076.

4. Abulkhir A, Limongelli P, Healey AJ, et al. Preoperative portal vein embolization for major liver resection: a meta-analysis. Ann Surg. 2008;247(1):49-57.

5. Guiu B, Bize P, Gunthern D, et al. Simultaneous biliary drainage and portal vein embolization before extended hepatectomy for hilar cholangiocarcinoma: preliminary experience. Cardiovasc Intervent Radiol. 2014;37(3):698-704.

6. van Lienden KP, van den Esschert JW, de Graaf W, et al. Portal vein embolization before liver resection: a systematic review. Cardiovasc Intervent Radiol. 2013;36(1):25-34.

7. Madoff DC, Abdalla EK, Gupta S, et al. Transhepatic ipsilateral right portal vein embolization extended to segment IV: improving hypertrophy and resection outcomes with spherical particles and coils. J Vasc Interv Radiol. 2005;16(2 Pt 1):215-225.

8. Farges O, Belghiti J, Kianmanesh R, et al. Portal vein embolization before right hepatectomy: prospective clinical trial. Ann Surg. 2003;237(2):208-217.

9. Nagino M, Nishio H, Ebata T, et al. Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up. Surgery. 2006;139(1):135-147.

10. Wiggers JK, Groot Koerkamp B, Cieslak KP, et al. Postoperative mortality after liver resection for perihilar cholangiocarcinoma: development of a risk score and importance of biliary drainage of the future liver remnant. J Am Coll Surg. 2016;223(2):321-331.

11. Olthof PB, Coelen RJ, Wiggers JK, et al. External biliary drainage following major liver resection for perihilar cholangiocarcinoma: impact on development of liver failure and biliary leakage. HPB (Oxford). 2016;18(4):348-353.

12. Luz JHM, Veloso Gomes F, Costa NV, et al. BestFLR Trial: Liver Regeneration at CT before Major Hepatectomies for Liver Cancer—A Randomized Controlled Trial Comparing Portal Vein Embolization with N-Butyl-Cyanoacrylate Plus Iodized Oil versus Polyvinyl Alcohol particles Plus Coils. Radiology. 2021;300(3):706-714.

13. Ali A, Ahle M, Björnsson B, et al. Portal vein embolization with N-butyl cyanoacrylate glue is superior to other materials: a systematic review and meta-analysis. Eur Radiol. 2021;31(7):5052-5062.

14. You Y, Kim K, Kim H, et al. Optimal timing of portal vein embolization (PVE) after preoperative biliary drainage for hilar cholangiocarcinoma. HPB (Oxford).2022;24(5):635-644.

15. Chun YS, Ribero D, Abdalla EK, et al. Comparison of two methods of future liver remnant volume measurement. J Gastrointest Surg. 2008;12(1):123-128.

16. Shindoh J, Vauthey JN, Zimmitti G, et al. Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including comparisons with the associating liver partition with portal vein ligation for staged hepatectomy approach. J Am Coll Surg. 2013;217(1):126-133.

17. Olthof PB, van den Esschert JW, Nio CY, et al. Liver volumetry and planimetric CT measurement to assess portal vein embolization hypertrophy response. Br J Surg. 2013;100(5):696-703.

Google Sites

Report abuse