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Embolization has become one of the primary techniques for treating iatrogenic bleeding. However since by default it causes vessel occlusion, it is mostly applicable to small, less important arteries or in peripheral branches that can be readily sacrificed. Proper technique generally allows a high degree of clinical success with minimal risk. With the ongoing development of stent grafts, endovascular treatment may also become the primary means of repairing larger, more critical vessels that must remain patent.

There is a significant body of evidence supporting the safety and effectiveness of radioembolization in the treatment of metastases to the liver. The aforementioned studies representing the collective clinical experience supporting the safety and therapeutic benefit of TheraSphere and SIR-Spheres in patients with metastatic disease to the liver suggest further investigation for additional applications. Disease states where further work should be initiated include HCC (primary therapy, randomization against TACE, bridge to transplantation, tumor downstaging), colorectal (combination with radiosensitizers [capecitabine, CPT-11] or newer agents [oxaliplatin, bevacizumab, cetuximab]), and metastatic neuroendocrine cancer to the liver. Furthermore, this technology appears to be ideal for extrahepatic applications, such as the treatment of renal cell carcinomas, meningiomas, as well as other malignancies that are readily accessible angiographically. There is also much to be gained from a more rigorous approach to investigating patient selection criteria, presentation of disease, and optimal dosimetry to obtain the desired therapeutic effect given these factors.

PVE is a safe technique allowing efficient preoperative hypertrophy of the FRL in selected cases. It is recommended to perform distal embolization rather than proximal occlusion or ligation. Embolic agents producing high local inflammatory reaction induce greater hypertrophy than others do.

PVE neither improves nor worsens long-term prognosis but it allows curative resection in patients that otherwise are considered as unresectable. Nowadays, it may be frequently combined with multiple other efficient therapeutic modalities (systemic or intraarterial chemotherapy, chemoembolization, radiofrequency ablation) in order to lead more patients with malignant liver tumor to radical surgery.

Current management strategies for neuroendocrine tumor hepatic metastases have relied on data from anecdotal evidence and retrospective studies involving small numbers of patients. It is unlikely that this situation will change in the near future, since prospective studies are difficult to perform in such a relatively rare and biologically heterogeneous disease. Embolotherapy is a widely accepted method of treatment for nonresectable hepatic metastases from neuroendocrine tumors. Long-term palliation of pain and hormonal symptoms is possible using repeated treatment. Both bland hepatic artery embolization and chemoembolization have been used, and there is no conclusive data to indicate which embolization method and which embolic agents are most efficacious.

Retrospective studies are of limited value in determining the exact effect of a certain form of treatment. Intra-operative blood loss depends not only on the type of surgery, but the individual skills of surgeon as well. Theoretically, a prospective and randomized study would be desirable for precisely evaluating the effects of pre-operative embolization. However, according to the nature of clinical studies, the necessity and possibility of conducting such a study are in question. Practically, pre-operative embolization of hypervascular bone metastases from renal cell carcinoma is a safe and minimally invasive procedure in experienced hands. Best results can be achieved with the use of PVA particles and when >70% of tumor blush is obliterated. This has become a standard pre-operative procedure for patients with hypervascular metastatic disease of bone from RCC.

Embolization has become one of the primary techniques for treating iatrogenic bleeding. However since by default it causes vessel occlusion, it is mostly applicable to small, less important arteries or in peripheral branches that can be readily sacrificed. Proper technique generally allows a high degree of clinical success with minimal risk. With the ongoing development of stent grafts, endovascular treatment may also become the primary means of repairing larger, more critical vessels that must remain patent.

Several questions remain unanswered, such as which is the best embolization agent, which is the best chemotherapeutic drug, or how can we increase the intratumoral concentration of the drug. The lack of large prospective randomized trials and the current difficulty in conducting meta-analyses on hepatic oncology embolotherapy, along with the absence of effective systemic therapy for unresectable primary and metastatic liver disease, urge intense efforts and the continuation of research on oncology embolotherapy. New developments in drug regimens, embolization materials and new variations in the embolization technique are rapidly changing the image of oncology embolotherapy and hopefully, will positively influence the outcome of treatment and patient survival.

The interventional radiologist should also bear in mind that successful embolotherapy depends on factors beyond the embolic agent selection, or the choice chemotherapeutic cocktail. Technical skills, experience, familiarity with the underlying pathologic processes, and appreciation of the importance for constructive collaboration with other specialties, are also essential for every successful oncology embolotherapy treatment.

There is a significant body of evidence supporting the safety and effectiveness of radioembolization in the treatment of metastases to the liver. The aforementioned studies representing the collective clinical experience supporting the safety and therapeutic benefit of TheraSphere and SIR-Spheres in patients with metastatic disease to the liver suggest further investigation for additional applications. Disease states where further work should be initiated include HCC (primary therapy, randomization against TACE, bridge to transplantation, tumor downstaging), colorectal (combination with radiosensitizers [capecitabine, CPT-11] or newer agents [oxaliplatin, bevacizumab, cetuximab]), and metastatic neuroendocrine cancer to the liver. Furthermore, this technology appears to be ideal for extrahepatic applications, such as the treatment of renal cell carcinomas, meningiomas, as well as other malignancies that are readily accessible angiographically. There is also much to be gained from a more rigorous approach to investigating patient selection criteria, presentation of disease, and optimal dosimetry to obtain the desired therapeutic effect given these factors.

PVE is a safe technique allowing efficient preoperative hypertrophy of the FRL in selected cases. It is recommended to perform distal embolization rather than proximal occlusion or ligation. Embolic agents producing high local inflammatory reaction induce greater hypertrophy than others do.

PVE neither improves nor worsens long-term prognosis but it allows curative resection in patients that otherwise are considered as unresectable. Nowadays, it may be frequently combined with multiple other efficient therapeutic modalities (systemic or intraarterial chemotherapy, chemoembolization, radiofrequency ablation) in order to lead more patients with malignant liver tumor to radical surgery.

PVE is a safe technique allowing efficient preoperative hypertrophy of the FRL in selected cases. It is recommended to perform distal embolization rather than proximal occlusion or ligation. Embolic agents producing high local inflammatory reaction induce greater hypertrophy than others do.

PVE neither improves nor worsens long-term prognosis but it allows curative resection in patients that otherwise are considered as unresectable. Nowadays, it may be frequently combined with multiple other efficient therapeutic modalities (systemic or intraarterial chemotherapy, chemoembolization, radiofrequency ablation) in order to lead more patients with malignant liver tumor to radical surgery.