Preliminary results from the largest global liver venous deprivation (LVD) registry—EuroLVD—confirms “high” hypertrophy and kinetic growth rate and “very low” rate of post-hepatectomy liver failure (PHLF), demonstrating the “safety” of LVD over portal vein embolization (PVE) in a real-world, multicentre setting. These data were presented during a scientific session at the European Conference of Interventional Oncology (ECIO) annual meeting (28 April–1 May 2024, Palma de Mallorca, Spain).
EuroLVD is an initiative that has been set up between interventional radiology and hepatobiliary surgery groups in Lausanne to collect information about LVD. “It’s almost copy and pasting what has been done for the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique,” lead investigator—and previous chairman of ECIO—Alban Denys (Centre Hospitalier Universitaire Vaudois [CHUV], Lausanne, Switzerland) told Interventional News.
ALPPS is a surgical technique that combines transection of liver parenchyma and the ligation of the portal vein to the diseased liver. It allows higher, “more efficient” degrees of hypertrophy of the future liver remnant (FLR) in a short time, Denys explained. However, studies have shown a high rate of morbidity and mortality associated with the procedure, such as the 2020 single-centre study conducted by Kosuke Kobayashi (University of Lausanne, Lausanne, Switzerland) which confirmed the superiority of liver venous deprivation (LVD) over portal vein embolization (PVE) alone, inducing faster hypotrophy of the future liver remnant.
“As more groups worldwide use this technique,” Denys said, “a more systematic exploration, including randomised controlled trials of multiple centres and registries of cases are paramount to confirm the efficiency of LVD compared to other techniques such as PVE or Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), the latter being associated with severe morbidity and mortality.”
In total, Denys et al identified 216 patients from centres in Switzerland, France, the USA, and the UK, the majority of whom had had a previous diagnosis of colorectal cancer or chloangiocarcinoma. Concerning procedural characteristics for LVD, Denys outlined that average procedure duration was 130 minutes and noted 6.5% rate of complication, including two pleural effusions or reports of chest pains. Median FLR and standardised FLR ratios prior to LVD were 35% and 32%, respectively. Following LVD, median FLR and standardised FLR “significantly increased” to 48% and 44%, corresponding to a median kinetic growth rate of 3.4% per week. Denys also noted that the median delay between LVD and surgery was 41 days.
Hepatectomy was performed in 160 patients—85 hepatectomies, 65 extended right hepatectomies, seven extended left hepatectomies and 3 other resections. He noted that 77 (48%) of patients experienced post-operative complications and five (3%) developed postoperative liver failure.
Presenting these data at ECIO, Denys confirmed that: “EuroLVD demonstrates the safety of LVD in a large real-world multicentre setting—hypertrophy and kinetic growth rate are high and the PHLF rate is very low. It is our approach that, the more liver you leave in place, the easier it is for surgery, for recovery and the shorter the stay in the intensive care unit.”
“I think this could impact the clinical practice of centres that are still not convinced on LVD,” Denys continued. “Our main messaging is to not be afraid to start. It’s a safe procedure, it’s not very complex and it enables better outcomes from your patient, so don’t be afraid to go for it—and even participate in the EuroLVD registry if you do implement the procedure.”
“The idea of LVD is to be more efficient than PVE but less morbid and with a lower mortality than ALPPS,” said Denys. In his team’s view, striking this balance may provide a “significant benefit” in terms of hypertrophy of the left lobe of the liver when resection of the right lobe is necessary, but the left lobe is “too small”, without additional morbidity/ mortality.
“The technique has only been invented a few years ago however, so there is not much depth in the literature,” he added. Aside from Kobayashi et al’s monocentric retrospective analysis, Denys noted that there are “almost no prospective data”, which led his team to build their comprehensive registry.
“The results are quite positive,” Denys commented. He explained that his teams’ intention is to provide this initial detail and subsequently subdivide their cohort by disease groups based on liver function characteristics recorded before patients underwent LVD. In doing so, Denys and his team will seek answers to questions, such as—is the liver normal? Has the patient received chemotherapy? Is it a cholestatic liver? Is it a cirrhotic liver? In asking these questions, they aim to define how LVD works in various groups.
“Ultimately, we have confirmed the previous monocentric studies which have provided optimistic data that have informed our present registry,” Denys said. “There is already a very positive signal supporting LVD and its superiority over PVE for every single patient.”
Looking to the future, Denys noted that observing marginal indications for liver preparation techniques, such as LVD and PVE, will be “very interesting” when they are able to analyse the final data of their registry.
“When your left liver lobe volume is at its limit, what preparation technique should you decide to go with, if at all? What do you get in terms of results? If you are able to shorten hospital stay and reduce morbidity, that’s very interesting information. There’s also room for expanding the indication for liver preparation techniques to broader indication criteria, as the technique has very low morbidity and this is what we want to confirm—the more liver you leave in place after surgery, the better the patient outcome in the post-operative period.” This, he stated, may be due to faster recovery time and less complications—all endpoints that he anticipates can be achieved with LVD, or at least this is what his team are seeing “at the moment”.
Finally, Denys added that interventionists should not be “afraid” to use LVD and hopes that any centre which begins to deploy the technique may consider becoming involved in the registry. His presentation of their preliminary data at ECIO is aimed to not only provide a small glance into the significance of their long-term data, but also to publicise their registry so that they might “gather even more patients”, bolstering final conclusions to be released in the summer.
