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Transarterial Radioembolization Versus Portal Vein Embolization Prior to Major Hepatectomy for Hepatocellular Carcinoma: A Comparison of Perioperative Outcomes
Alexa J. Hughes
*, Dhruv Patel, Thomas K. Maatman, C. Max Schmidt, Eugene Ceppa, Nicholas Zyromski, Michael House, Alexandra Roch, Cary Jo Schlick, Ryan Ellis
Surgery, Indiana University School of Medicine, Indianapolis, IN
Objectives: Portal vein embolization (PVE) is a standard approach for preoperative liver hypertrophy prior to major hepatectomy for hepatocellular carcinoma (HCC), but transarterial radioembolization with Yttrium-90 (Y90) has emerged as an alternative that provides both locoregional tumor control and contralateral hypertrophy. However, national practice patterns and outcomes between these two modalities are poorly characterized. The objective of this study is to compare utilization patterns and perioperative outcomes following major hepatectomy for HCC preceded by PVE versus Y90.
Methods: The ACS-NSQIP database was queried for patients undergoing right hepatectomy or trisegmentectomy for HCC with documented preoperative PVE or Y90 from 2014-2024. Left hepatectomies were excluded as preoperative hypertrophy is rarely required prior to left hepatectomy. Univariable and multivariable Firth logistic regression analysis (MVA) were performed to identify factors associated with utilization, perioperative transfusion, post-hepatectomy liver failure (PHLF), and serious morbidity.
Results: Of 247 patients, 169 (68%) underwent PVE and 78 (32%) underwent Y90. Baseline characteristics were similar between groups. Y90 utilization increased from 17% in 2014 to 33% in 2024 (
P=0.11). On multivariable analysis, APRI ≥0.7 was associated with decreased likelihood of Y90 utilization (OR 0.47, 95% CI 0.21-0.99,
P=0.048). Perioperative outcomes were comparable between groups, including rates of PHLF (18% vs 19%,
P=0.92), serious morbidity (36% vs 35%,
P=0.93), and 30-day mortality (4.1% vs 5.1%,
P=0.75). On multivariable analysis, neither perioperative transfusion, PHLF, nor serious morbidity differed by hypertrophy approach.
Conclusions: Utilization of trans-arterial interventions such as Y90 prior to major hepatectomy for HCC has increased over the past decade. Despite potential differences in case selection, perioperative outcomes following Y90 are comparable to those following PVE. These findings support Y90 as reasonable alternative to PVE for preoperative liver hypertrophy in appropriately selected patients with HCC undergoing right hepatectomy or trisegmentectomy.
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