Why your surgeon is asking for this
The liver is the only organ in the body that grows back. When part of it is removed, the rest enlarges to take over the work — but the part that’s left has to be big enough to keep you healthy in the meantime. Surgeons call that part the future liver remnant (FLR). If your tumor is large or sits in an inconvenient place, the planned surgery may leave behind an FLR that’s just a little too small to safely do the work on day one. Operating on that anatomy carries a real risk of post-hepatectomy liver failure (PHLF).
PVE solves that problem ahead of time. By gently blocking blood flow to the side of the liver containing the tumor, the procedure redirects flow to the healthy side, which then grows — typically gaining 30 to 50 percent in volume over 3 to 6 weeks.1,2 By the time of surgery, the future liver remnant is large enough to take over.
Our physicians are leaders in portal vein embolization
Dr. Shaikh and partners are senior authors of a peer-reviewed article on PVE techniques and outcomes published in the journal Life, examining how to maximize remnant liver hypertrophy with contemporary embolic agents and combination strategies.1
Will I need PVE?
The decision is based on imaging — specifically a CT or MRI measurement of how much liver you’d have after the planned operation, expressed as a percentage of your total liver volume. The cutoff for a “safe” remnant depends on the health of the rest of your liver:
- At least 20 percent if the rest of your liver is healthy
- At least 30 percent if you’ve had several months of chemotherapy (common after FOLFOX or FOLFIRI for colorectal liver metastases)
- At least 40 percent if you have cirrhosis or significant scarring
The most common reasons for PVE referral are hepatocellular carcinoma (HCC), colorectal liver metastases, and cholangiocarcinoma (intrahepatic, hilar, and Klatskin tumors). Less commonly: gallbladder cancer, neuroendocrine liver metastases, and selected non-colorectal metastases.
What the day looks like
You’ll come to the hospital in the morning, fasting from the night before. The procedure is done in an interventional suite under sedation or general anesthesia.
We numb a small spot on the skin over your liver and use ultrasound to advance a thin tube — about the diameter of a pen lead — into one of the portal vein branches. Live X-ray imaging shows the inside of the portal venous tree, and we close the branches feeding the tumor side with a permanent medical-grade glue (n-butyl cyanoacrylate with ethiodized oil), sometimes combined with vascular plugs, coils, or particles. When an extended right hepatectomy is planned, we usually treat the segment IV branches as well, to maximize growth of the left side that will remain.
The procedure takes 60 to 120 minutes. You’ll stay overnight for observation and go home the next day.
Recovery and what comes next
The first few days, expect mild soreness on the treated side, sometimes a low-grade fever, and modest temporary changes in your liver enzymes — all normal and self-resolving. There are no stitches to remove.
The growth happens quietly inside, while you go on with your life. Three to six weeks after PVE, a repeat CT or MRI measures how much your future liver remnant has grown. When the growth is adequate, your surgeon proceeds with the planned hepatectomy. Timing is coordinated between your surgeon, your medical oncologist when chemotherapy is part of the plan, and our team.
Are there other options besides PVE?
Yes — and your team will choose the right one for your situation. PVE has been standard for nearly 30 years, and the field has continued to advance:
- Hepatic venous deprivation (HVD) combines PVE with hepatic vein embolization on the same side; hypertrophy is faster and more robust than PVE alone in published series.3
- Radiation lobectomy with Y-90 uses transarterial radioembolization to both treat the tumor and induce contralateral growth — particularly useful in HCC.
- ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) is a two-stage surgical approach with faster hypertrophy than PVE but a higher complication rate.4
The right strategy is chosen by the multidisciplinary team based on your tumor, your liver, and the planned operation.
References
- Charles J, Nezami N, Loya M, Shube S, Davis C, Hoots G, Shaikh J. Portal Vein Embolization: Rationale, Techniques, and Outcomes to Maximize Remnant Liver Hypertrophy with a Focus on Contemporary Strategies. Life (Basel). 2023;13(2):279. doi:10.3390/life13020279.
- 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.
- Guiu B, Quenet F, Escal L, et al. Extended liver venous deprivation before major hepatectomy induces marked and very rapid increase in future liver remnant function. Eur Radiol. 2017;27(8):3343–3352.
- Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings (ALPPS). Ann Surg. 2012;255(3):405–414.
Frequently asked questions
What is portal vein embolization?
PVE is an image-guided procedure performed before major liver surgery to grow the part of the liver that will remain after resection. By blocking blood flow to the side of the liver containing the tumor, the healthy side hypertrophies and becomes large enough to safely take over after the diseased part is removed.
Why do I need PVE before liver surgery?
Major hepatectomy is safe only when the future liver remnant (FLR) is large enough to support the body’s needs. If the FLR is too small, the patient is at risk of post-hepatectomy liver failure. PVE is the standard procedure to grow the FLR to a safe volume in the weeks before resection.
How much does the liver grow, and how long does it take?
On average, the future liver remnant gains approximately 30 to 50 percent in volume in the 3 to 6 weeks after PVE. Repeat liver volumetry on CT or MRI confirms adequate hypertrophy before scheduling the operation.
How is PVE different from ALPPS or hepatic venous deprivation?
ALPPS is a more aggressive surgical strategy that produces faster but riskier hypertrophy. Hepatic venous deprivation combines portal vein embolization with embolization of the hepatic vein on the same side and produces faster, more robust hypertrophy than PVE alone. The right strategy depends on the tumor, the patient, and the planned operation, and is decided by the multidisciplinary hepatobiliary team.
Who is a good candidate?
PVE is for patients who are otherwise resection candidates but have an FLR predicted to be too small for safe hepatectomy. The FLR threshold depends on the underlying liver — about 20 percent in healthy parenchyma, 30 percent with chemotherapy-associated injury, and 40 percent in cirrhosis. Candidacy is always determined by the multidisciplinary hepatobiliary team.
