Combined simultaneous embolization of the portal vein and hepatic vein (double vein embolization) – a technical note about embolization sequence

BACKGROUND: Simultaneous portal vein embolization (PVE) and hepatic vein embolization (HVE) has been shown to be feasible, safe and lead to a faster growth of future liver remnant (FLR) than PVE alone. The objective of this study is to highlight different technical aspects as well as importance of embolization order. MATERIALS AND METHODS: Seven patients were treated with simultaneous PVE and HVE. In three cases, HVE was performed first followed by PVE and in four cases the other way around. Portal vein branches were embolized using Glubran-Lipiodol mixture in all cases. Hepatic veins were embolized using Amplatzer II plugs sized 8–20 mm. Specific consideration was given to depth of glue penetration in the portal vein defined by visible branch order on the treated side. RESULTS: Six of seven patients were discharged home the same day. One patient with infected tumor necrosis died of liver failure 40 days later, otherwise there were no periprocedural clinical complications. Median glue penetration was to the 5th order (4th – 5th) when PVE was performed first and 3rd order (2nd - 4th) when PVE was performed after HVE. In one PVE first case, glue spillage was seen due to marked reduced flow in the right portal vein. There was sufficient FLR growth for subsequent surgical resection in the remaining six patients. CONCLUSION: PVE should be performed prior to HVE because the reduced flow in the portal vein after HVE leads to less deep glue penetration with presumably increased risk of contralateral spillage.