What is Portal Vein Embolization?
Portal vein embolization (PVE) is a procedure that can be part of the treatment plan for patients with liver cancer that require surgery. Patients with primary liver cancer (cancer that originated in the liver) or secondary liver cancer (cancer that has spread to the liver from another location) that require surgical resection of the diseased section of their liver may be recommended for this procedure by their primary physician, surgeon, or oncologist.
The liver is unique because it has two blood supplies. The portal vein provides 75 percent of the liver’s blood supply and the hepatic artery supplies the remaining 25 percent. The liver also has the ability to regenerate itself if at least 30% of the organ remains intact after surgical removal of the diseased tissue. In the past patients with large or multiple tumors were not considered suitable candidates for surgery because too much of their liver would need to be removed, severely compromising successful organ function.
PVE works by blocking the portal venous flow to the diseased segment of the liver and redirecting flow to the part of the liver that is expected to remain after surgery. This blockage stimulates hypertrophy (growth) of the healthy liver segment and causes the embolized diseased portion of the liver to start to shrink. This will aid your surgeon in removing the maximum amount of disease from your liver during surgery.
This procedure can increase a patient’s chances of being a candidate for surgical removal of liver cancer. The procedure is usually done as a same day outpatient procedure.
Why is it done?
This procedure may increase the chances your surgeon can completely remove the diseased portion of your liver during surgery. This procedure has the potential to reduce complications and shorten the number of days you stay in the hospital following liver resection surgery. This procedure can be repeated if needed before liver resection surgery to optimize the growth of the healthy portion of your liver.
What are the risks?
There are two main risks related to this procedure. The immediate risk is bleeding. Before the procedure we make sure all your coagulation studies are normal. We also use plugs to block the procedure area to avoid bleeding complications.
The second risk of this procedure is embolization of the normal part of the liver. This could happen if the materials we use to block the branches of the portal vein going to the diseased part of the liver migrate to normal portions of the liver. Thankfully, using image guidance we are able to visualize the injection of the material used to block these branches as we do it, so we can avoid this problem.
There is a small chance of allergic reaction to the contrast material used to view your vessels with X-ray. There is also a risk for kidney damage from the contrast material, especially for patients with diabetes or pre-existing kidney disease. The effects from the contrast vary for every patient. Medicines and IV fluids are given to help prevent or relieve most of these side effects. Also, steps can be taken before the procedure to prevent allergic reactions to contrast and lessen the chance of kidney damage for those at risk.
Reasons to avoid this procedure?
Certain conditions may limit you from being eligible for this procedure. These include patients with severely compromised liver function (advanced cirrhosis) and patients with uncontrolled systemic diseases such as diabetes or renal failure. These conditions can significantly limit the hypertrophy (growth) of the liver after the procedure.
A CT or MRI with contrast is performed before the procedure to make sure the portal vein has normal flow. In general, patients who have hepatic artery thrombosis or have previously undergone chemoembolization should avoid this procedure.
Patients who have occlusion of the portal vein, as a general rule, cannot undergo this procedure.
How do you prepare?
Usually this procedure is performed with IV sedation and local anesthesia. You will need to be fasting for 8 hours before the procedure. We recommend no eating or drinking after midnight before the procedure. Generally, you should take your daily morning medications with a small sip of water.
If you take blood thinners you need to stop before the procedure. Please refer to your pre-procedure instructions for detailed instructions about your medications.
Please leave all valuables such as jewelry, credit cards and money at home on the day of the procedure. Family members may wish to bring a magazine or book to read during the extended wait time.
After checking in at Patient Registration, you will be directed to the pre-procedure unit on 2B. Once in the department a nurse will prepare you for the procedure. This preparation will include changing into a gown, a nurse taking your vital signs, starting an IV in your arm, lab tests and giving you IV fluids and IV medications (antibiotics, anti-nausea, etc).
How is the procedure done?
The procedure is performed in the catheterization laboratory, also called “cath lab”. An entire team will be taking care of you during the procedure including 2 nurses, a radiography technologist and the physician. In the procedure room, the nurse will help you lie on an exam table. You will be connected to heart rate, oxygen saturation and blood pressure monitors. IV medicine will be given to relax you (moderate sedation). Your groin area will be shaved and washed with a special soap and covered with sterile sheets. Local anesthetic medicine is injected into the area. You will feel some burning as the medicine is given. Once it takes effect, the area will be numb. The procedure time varies, but usually takes 1 to 2 hours. Throughout the procedure, medication is given through your IV throughout the procedure to keep you comfortable. Your oxygen saturation, blood pressure and pulse are checked closely during and after the procedure.
Guided by ultrasound, a catheter is inserted through the skin and into the blood vessels that go into your liver. The interventional radiologist will use x-ray (fluoroscopy) to guide this catheter into the portion of the portal vein that needs to be blocked. Once the catheter has been confirmed to be in the correct location tiny particles are injected into the catheter. These particles will block the blood flow in the desired portions of the portal vein. This may cause discomfort. The procedure time varies, but usually takes 1 to 2 hours. Your blood pressure and pulse are checked closely during and after the procedure. After the procedure is complete the catheter will be removed and a band-aid is used to cover the site.
What you can expect after the procedure?
After the procedure you will go to the post surgical area at El Camino Hospital (unit 2B). There we will be able to monitor your vital signs and the site of the procedure. In general, you will be there for 1-2 hours, but some patients will be admitted to stay at the hospital for observation and pain management.. We want to be sure you do not have any problems before you go home.
Don’t worry. You will be able to eat and drink after the procedure. You will be able to see your family members soon after the procedure.
At home, we recommend that you take it slow over the next week. You should not drive or operate heavy machinery until the following day after the procedure.
How long does it take to recover?
Complete recovery usually takes 7 to 10 days. You may feel dull pain in your right upper abdomen and fatigue during this time. You should have a follow-up appointment in 2 weeks after your procedure.
When should you call your physician?
Signs of infection at the procedure site (redness, tenderness, swelling and/or pain).
New onset or worsening of abdominal pain.
Severe lightheadedness and dizziness.
Fever of >101F
You can reach your Interventional radiologist at (650) 404-8445
If you receive sedation during the procedure, you should not drive, consume alcohol, operate heavy machinery or make any important decisions for the remainder of the day.
You may resume your regular activities (including driving) after 24 hours, unless you have been restricted for another reason.
No exercising, lifting heavy objects or strenuous activity for the next 7 days.
Some pain or discomfort at the site of the procedure may be normal. However, it should not be getting worse.
It is also normal to have discomfort in the right shoulder area after the procedure, due to referred pain.
Unless you have been told to avoid certain medications, you may use over the counter medication such as Acetaminophen/Tylenol or Ibuprofen/Advil/Motrin for minor discomfort, unless you are restricted from taking these medications.
Usually the pain is not severe and does not require stronger medications. If your pain is very severe it could indicate a bleeding complication.
If you feel that Tylenol or Advil are not enough for pain control, please contact the Vascular and Interventional Radiology Clinic at (650) 404-8445.
You can resume your normal diet. Some patients may develop nausea after the sedation. Therefore light meals are recommended until you know that you can eat without problems.
You can take a shower tonight. You should not soak the wound in water (ie. bath and swimming pool) for 1 week.