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Marasco et al. Hepatoma Res 2020;6:32 I http://dx.doi.org/10.20517/2394-5079.2019.54 Page 11 of 17

Interventional radiology
Portal vein embolization (PVE) is an interventional radiological procedure. It consists of embolization of
portal branches in the future resected liver, thus shifting blood flow to the FLR, allowing its hypertrophy
before major hepatectomy. By increasing the volume of FLR, the risk for PHLF is decreased, even after
extended liver resection [117] . Furthermore, preoperative PVE reduces intra-operative hepatocyte injury caused
by the sudden increase in portal pressure at resection. Current guidelines recommend PVE for cirrhotic
patients and an estimated FLR of ≤ 40%, or normal patients with an intended FLR of < 20% [150] .

CT volumetry should be performed 3-4 weeks after PVE to assess the degree of hypertrophy, which if > 5%,
is associated with improved patient outcomes [115] . A study by Capussotti et al. [151] reported a FLR hypertrophy
of 30%-40% in 4-6 weeks in more than 80% of patients, and was therefore able to prepare patients for
hepatectomy after that period. Hepatic arterial buffer response, after reduction of portal blood flow post-
PVE, can increase the size of the tumor. However, PVE preceded by trans-arterial chemoembolization
(TACE) may prevent this by causing tumour necrosis [152] . RLE on Gd-EOB-DTPA-MRI has also been
evaluated both pre- and post-PVE. In particular, the corresponding increase in RLE of the remnant liver
at 14 and 28 days after PVE is significantly lower in patients who develop PHLF than in those who do not.
[67]
Similar results were found comparing patients without or with mild PHLF versus those with severe PHLF .
CONCLUSION
PHLF is still an event associated with major concerns by surgeons, especially in elderly patients. Several
attempts have been made to identify the best non-invasive predictor of PHLF, in order to introduce a pre-
operative tool for the assessment of such risk in routine clinical practice. Particularly, and when available,
imaging parameters allow the identification of peri-operative risk factors related to the underlying cirrhosis,
the volume of the liver remnant and patient related characteristics, mainly associated with the elderly such
as sarcopenia and low bone mineral density. Otherwise, in other settings, LSM as well as ICG-r15 and the
ALBI score are useful NITs able to mirror hepatic dysfunction and portal hypertension, and are thus being
recommended before surgery for PHLF risk assessment. However, there is still poor evidence for their
application in older patients. Further prospective and well-designed studies evaluating the ability of these
NITs in predicting PHLF in the elderly are thus needed.

DECLARATIONS
Authors’ contributions
Conceptualized and designed the review: Marasco G, Colecchia A
Wrote, reviewed and edited the manuscript: Marasco G, Milandri M, Rossini B, Alemanni LV, Dajti E,
Ravaioli F
Provided the tables: Alemanni LV, Dajti E
Reviewed and approved the final manuscript as submitted: Colecchia A, Renzulli M, Golfieri R, Festi D
Read and approved the final manuscript: All authors

Availability of data and materials
Not applicable.

Financial support and sponsorship
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Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.