From Flow Modulation to Resection: First in Human Combination of Liver Venous Deprivation and Balloon-Occluded...

Curative surgical treatment of hepatocellular carcinoma (HCC) is limited to liver transplantation (LT) and liver resection (LR), but many patients are ineligible due to insufficient future liver remnant (FLR). Liver venous deprivation (LVD) induces more rapid hypertrophy than portal vein embolization (PVE) but may trigger the hepatic arterial buffer response (HABR), leading to increased arterial inflow and potentially stimulating tumor growth, especially for HCC. We report a 75-year-old male with HCC and advanced fibrosis, in whom extended LVD was followed 3 days later by balloon-occluded transarterial chemoembolization (B-TACE) to coincide with HABR, providing more selective tumor control, higher intratumoral drug concentration, and low risk of non-target embolization compared to standard TACE, which is desirable in the field of deprived livers. Within three weeks, FLR increased from 33% to 51% with degree of hypertrophy (DH) 15.8%, kinetic growth rate (KGR) 5.3%/week and relative growth rate (RGR) 47,6% accompanied by near-complete tumor response, enabling curative hepatectomy. Despite postoperative complications, R0 resection was achieved. This case illustrates the technical feasibility of sequential LVD followed by B-TACE in this specific order, suggesting that such an approach may help reduce the hepatic arterial buffer response within the tumor, support rapid hypertrophy, and facilitate resectability in carefully selected patients, including elderly individuals with comorbidities. To the best of our knowledge, and based on a comprehensive literature search, this is the first reported case of LVD-B-TACE.