Endovascular flow reduction after portal vein arterialization: a technical note

Portal vein arterialization (PVA) is a salvage technique used to preserve hepatic and biliary perfusion when hepatic arterial reconstruction is not feasible. Excessive arterioportal inflow, however, may cause clinically relevant portal hyperperfusion with ascites, gastrointestinal or biliary bleeding, and hepatic dysfunction. This technical note describes a practical interventional radiology approach to temporary, graded, and definitive endovascular flow modulation after PVA.

All consecutive patients with native livers who underwent PVA at a tertiary referral center between February 2020 and February 2024 were retrospectively reviewed. Cases requiring endovascular flow reduction for portal hyperperfusion were analyzed with regard to indication, timing, technique selection, technical feasibility, and short-term clinical course. Technical success was defined as correct device deployment with immediate angiographic reduction of arterioportal inflow. Procedure-related complications were classified according to CIRSE.

Six patients required endovascular flow modulation after PVA, accounting for nine procedures. Balloon occlusion with repositioning was used as a temporary measure and a hemodynamic test when definitive closure was considered premature. Stent-based flow modulation was used for graded reduction when persistent hyperperfusion required decompression but residual shunt perfusion was to be preserved. Coil embolization was used for definitive closure in refractory cases or when complete occlusion was deemed acceptable. Technical success was achieved in 7/9 procedures and clinical success in 5/9. Despite technically successful flow reduction, two patients died from septic multiorgan failure.

Endovascular flow modulation after PVA is technically feasible using complementary IR strategies. Balloon occlusion is useful for temporary or test reduction, stent techniques for partial flow modulation, and coil embolization for definitive closure. Technique selection should be guided by timing after PVA, clinical presentation, and anticipated hepatic tolerance rather than by a uniform treatment algorithm.