Feasibility of Percutaneous Intrahepatic Split by Microwave Ablation (PISA) After Portal Vein Embolization for Hypertrophy of Future Liver Remnant: The Radiological Stage-1 ALPPS

  • Alessandro Lunardi
  • Rosa Cervelli
  • Duccio Volterrani
  • Saverio Vitali
  • Carlo Lombardo
  • Giulia Lorenzoni
  • Laura Crocetti
  • Irene Bargellini
  • Daniela Campani
  • Luca Emanuele Pollina
  • Roberto Cioni
  • Davide Caramella
  • Ugo Boggi
Technical Note



To assess the feasibility of radiological stage-1 ALPPS, associating liver partition and portal vein ligation for staged hepatectomy, by combining portal vein embolization (PVE) with percutaneous intrahepatic split by ablation (PISA).

Materials and Methods

Three patients (mean age 65.0 ± 7.3 years) underwent PVE and PISA. PISA was performed 21 days after PVE by microwave ablation to create a continuous intrahepatic cutting plane. Abdominal CT examinations were performed before and after PVE and PISA. The future liver remnant (FLR) volume was calculated by semiautomatic segmentation, and increase was reported as a percentage of the pre-procedural volume. The FLR/body weight (FLR/BW) ratio was calculated; a ratio greater than 0.8% was considered sufficient for guaranteeing adequate liver function after surgery. The liver function before and after PISA was also evaluated by 99mTc-mebrofenin hepatobiliary scintigraphy. Patients’ laboratory tests, performance status, ability to walk were assessed before and after PVE and PISA procedures.


No procedure-related complications were recorded. The FLR volume increase in each patient was 42.0, 33.1 and 30.4% within 21 days of PVE and 109.3, 68.1 and 71.7% within 10 days after PISA. The FLR/BW ratios were 0.76, 0.66, 0.63% and 1.13, 0.83, 0.83% after PVE and PISA procedures, respectively. Two patients underwent successful right hepatectomy; in one patient, despite 1.13% FLR/BW, surgery was not performed because of the absolute rejection of blood transfusion due to the patient’s religious convictions.


Radiological stage-1 ALPPS is a feasible, minimally invasive option to be further investigated to become an effective alternative to surgical stage-1 ALPPS.


Portal vein embolization Microwave ablation ALPPS FLR hypertrophy Major hepatectomy Intrahepatic split 


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2018

Authors and Affiliations

  • Alessandro Lunardi
    • 1
  • Rosa Cervelli
    • 1
  • Duccio Volterrani
    • 3
  • Saverio Vitali
    • 1
  • Carlo Lombardo
    • 2
  • Giulia Lorenzoni
    • 1
  • Laura Crocetti
    • 1
  • Irene Bargellini
    • 1
  • Daniela Campani
    • 4
  • Luca Emanuele Pollina
    • 4
  • Roberto Cioni
    • 1
  • Davide Caramella
    • 1
  • Ugo Boggi
    • 2
  1. 1.Division of Diagnostic and Interventional Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, Azienda Ospedaliero Universitaria PisanaUniversity of PisaPisaItaly
  2. 2.Division of General and Transplant Surgery, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
  3. 3.Division of Nuclear Medicine, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
  4. 4.Division of Pathology, Department of Laboratory MedicineUniversity of PisaPisaItaly

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