Portal vein embolization (PVE) is the standard strategy to increase future liver remnant (FLR) before major hepatectomy, but its limitations-variable hypertrophy, slower kinetics, and clinically relevant dropout from insufficient FLR growth or tumor progression-have accelerated interest in alternative approaches. Liver venous deprivation (LVD), combining portal inflow deprivation with ipsilateral hepatic venous outflow occlusion, has a strong physiological rationale: It may intensify regenerative signaling and reduce compensatory collateralization within the embolized liver, thereby promoting faster FLR increase. Emerging observational evidence and multicenter experiences suggest that dual-vein strategies can shorten time to adequate FLR and may improve the probability of timely resection in selected high-risk candidates, without a clear safety penalty when performed in experienced centers. However, current data are heterogeneous in patient selection, technique, and endpoints; volumetric hypertrophy does not always translate into functional gain, particularly in injured or cholestatic livers. Therefore, LVD is not yet ready to universally replace PVE, but it is increasingly reasonable as a first-line alternative in carefully selected patients, ideally supported by multidisciplinary selection, standardized reporting, and functional FLR assessment. Ongoing randomized trials and harmonized outcome definitions will be decisive to establish whether LVD should become the new reference or remain a complementary option.
Gruttadauria et al. (2026) studied this question.