Increased Resectability after Simultaneous Portal and Hepatic Vein Embolization (PVE/HVE) Compared to PVE Alone in Patients with Small FLRs - A DRAGON GROUP Analysis

Introduction: Major liver resections in patients with a small Future Liver Remnant (FLR) can only be performed safely after induction of adequate FLR-hypertrophy to reduce the risk of post-hepatectomy liver failure (PHLF). Hypertrophy induced by Portal Vein Embolization (PVE) is slow and 20-30% of patients are not resected after this procedure. Combining Portal and Hepatic Vein Embolization (PVE/HVE) accelerates FLR hypertrophy, whether this increases resectability is studied in this analysis. Methods: All participating centers in the DRAGON COLLABORATIVE that had already performed >5 PVE/HVE between 2016 and 2019 were asked to contribute cases of PVE/HVE or PVE. Osirix MD was used for volumetric assessment. Multivariable analysis was performed for the endpoints: resectability, FLR hypertrophy, and major complications (Clavien-Dindo >IIIA). Results: From 7 DRAGON centers, 39 PVE/HVE and 160 PVE cases were included. After PVE/HVE, resectability (90% vs. 68%, p=0.007) and FLR hypertrophy (59% vs. 48%, p=0.02) were higher than PVE alone. 90-day mortality (3% vs. 16%, p=0.15) and major complications (26% vs. 34%, p=0.55) did not significantly differ between groups. PVE/HVE was not a significant risk factor for major complications, but it was an independent predictor for survival and hypertrophy. Results were confirmed via multivariable analysis. Conclusion: PVE/HVE resulted in increased resectablity and liver growth compared to PVE alone. Complications and mortality rate did not differ between PVE/HVE and PVE. Superiority of PVE/HVE over PVE will be investigated in the prospective DRAGON trials.