Transcatheter arterial embolization-salvaged ALPPS, a novel ALPPS procedure especially for patients with hepatocellular carcinoma and severe fibrosis/cirrhosis

Background:The associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)for hepatocellular carcinoma(HCC)with fibrosis/cirrhosis is often associated with limited growth of future liver remnant(FLR).We introduced a new procedure named transcatheter arterial embolization-salvaged ALPPS(TAE-salvaged ALPPS)which was shown to be especially suitable for HCC patients with cirrhosis or fibrosis who failed adequately to respond to conventional ALPPS.The short-term efficacy and safety for the TAE-salvaged ALPPS on patients with HCC and fibrosis/cirrhosis were studied.Methods:Consecutive HCC patients who underwent TAE-salvaged ALPPS in our hospital between November 2016 and June 2020 were retrospectively studied.The new ALPPS procedure included conventional ALPPS stage-1 using associating liver partition and portal vein ligation.When FLR failed to reach sufficient hypertrophy,TAE was carried out 2 weeks later followed by liver resection 3 weeks after ALPPS stage-1.Results:Nine of 10 patients had a single tumor(median diameter 14.0 cm,range,5.2-17 cm).The remaining patient had multiple tumors(diameter of one tumor 14.0 cm,and two satellite foci 2.0 and 3.0 cm).R0 resection was achieved in all patients(100%)after a median of 21 days.Six patients had cirrhosis,1 had METAVIR grade-3 fibrosis,and 3 had METAVIR grade-2 fibrosis.The median increase in FLR volume after TAE-salvaged ALPPS was 69.7%(34.4-143.9%).The absolute and relative kinetic growth rates(KGRs)were 9.9(7.1-17.3)mL/day and 3.4%(1.9-7.2%)/day,respectively.The median absolute KGRs were 15.7,2.6,and 19.5 mL/day in the first,second,and third postoperative weeks after ALPPS stage-1,respectively.The rapid increase in KGR on the third week was induced by TAE.The overall postoperative morbidity rates were 50,0%(5/10),20.0%(2/10)and 70.0%(7/10)after ALPPS stage-1,TAE and ALPPS stage-2,respectively.The 90-day mortality rate was 10.0%(1/10).The median overall survival was 40 months.Conclusions:The new TAE-salvaged ALPPS induced significant increases in FLR volumes within 3 weeks in patients with HCC and fibrosis/cirrhosis.The procedure is promising in treating patients with HCC and fibrosis/cirrhosis who fail to achieve sufficient FLR hypertrophy after conventional ALPPS stage-1.