Preoperative Transarterial Embolization Research Articles

Preoperative transarterial embolization using gelatin sponge for hypervascular bone and soft tissue tumors in the pelvis or extremities.

Preoperative transcatheter arterial embolization for hypervascular bone and soft tissue tumors plays an important role in reducing intraoperative blood loss (IBL). To evaluate the use of a gelatin sponge in preoperative transcatheter arterial embolization for hypervascular bone and soft tissue tumors in the pelvis or extremities. Thirty-seven patients (21 men, 16 women; median age, 61 years; age range, 23-79 years) underwent preoperative transcatheter arterial embolization between April 2004 and January 2015. Medical records and images were reviewed, and the technical success rate, clinical success rate, and complications were evaluated. Technical success was defined as a devascularization rate of 75% or higher, and clinical success was defined as intraoperative blood loss (IBL) <1500 mL in cases undergoing surgery within 3 days of transarterial embolization and <3000 mL in cases operated 4 or more days later. Tumor sizes were in the range of 2.0-13.0 cm (median, 5.0 cm). The devascularization rate was decreased by >75% at follow-up angiography in all cases, and the technical success rate was 100 % (37/37). The median IBL was 491 mL (range, 30-3800 mL), and the clinical success rate was 89% (33/37). The minor complication of local pain was observed in 13 out of 37 cases (35%) during or after embolization, but was controllable by an analgesic. Preoperative transarterial embolization using a gelatin sponge appears to be feasible and safe, and may contribute to decreasing IBL.

Does preoperative transarterial embolization decrease blood loss during spine tumor surgery?

This paper aimed to evaluate the effect of preoperative transarterial embolization (TAE) on estimated blood loss (EBL) during surgical excision of the vertebral tumors. Three hundred and forty-eight patients with spinal tumors were retrospectively analyzed. The preoperative TAE group consisted of 190 patients and the control group consisted of 158 patients. Gelatin sponge particles mixed withy contrast agent were used in the TAE group to embolize the tumor-feeding artery. The factors evaluated included: the time interval between embolism and surgery; the number of vertebrae involved by the tumor; pathological type of tumor; surgical approach; extent of excision and instrumental fixation. The time interval (P = 0.4669)between embolism and surgery had no significant correlation with EBL during surgery. The pathological diagnosis of vertebral tumor such as plasma cell myeloma, giant cell tumor, chondrosarcoma, hemangioma and metastasis had no significant correlation with EBL between the TAE group and control group during surgery, while the EBL of chordoma in the TAE group was significantly higher than that in the control group (p = 0.0254). The number of vertebrae involved (p = 0.4669, 0.6804, 0.6677), posterior approach (p = 0.3015), anterior approach (p = 0.2446), partial excision (p = 0.1911) and instrumental fixation (p = 0.1789) had no significant correlation with EBL during surgery between the TAE group and the control group. This study showed that preoperative TAE of the spinal tumor had no significant effect on intra-operative blood loss during surgical excision of the spinal tumor. In view of the risk of embolism, this method should be carefully considered.

Does preoperative transarterial embolization decrease blood loss during spine tumor surgery?

Does preoperative transarterial embolization decrease blood loss during spine tumor surgery?

Epithelioid haemangioendothelioma of the scapula in a child: A case report and review of the literature

Epithelioid haemangioendothelioma (EHE) is a vascular tumour which rarely affects bone. A 10-year-old girl presented with slow onset of swelling of the scapula for 6 months. Radiology revealed a destructive lesion of the scapula. Histology confirmed epithelioid haemangioendothelioma. Pre-operative transarterial embolisation was performed to decrease the vascularity of the tumour. The tumour was completely resected with the entire scapula. Post-operatively the child improved with useful function and a stable shoulder 13 months later. Large, isolated EHE of the scapula has not been reported in children.

Spontaneous Rupture of Renal Cell Carcinoma in a Horseshoe Kidney: A Case Report

Spontaneous rupture of renal cell carcinoma (RCC) in a horseshoe kidney has not been described previously. We report a case of this condition in a 52-year-old man with a chief complaint of back pain. Spontaneous rupture of renal tumor in a horseshoe kidney was diagnosed by enhanced computed tomography, and treated with transarterial embolization (TAE). Radical heminephrectomy was performed after TAE. This case indicates that enhanced computed tomography and renal angiography are desirable prior to surgery for evaluation of the anatomical variations of a horseshoe kidney, and that preoperative TAE may be beneficial for achieving reliable vascular control. World J Nephrol Urol. 2015;4(2):218-221 doi: http://dx.doi.org/10.14740/wjnu215w

Preoperative embolization of hypervascular spinal tumors: current practice and center experience

Preoperative transarterial embolization of hypervascular spinal tumors has been extensively used, and is considered to be a highly effective adjuvant technique in reducing intraoperative blood loss during surgery. Moreover, it has been reported to increase the feasibility and safety of the surgical procedure, leading to better surgical outcomes. We review the English literature in an attempt to identify indications, appropriate timing of embolization in relation to surgery, technical aspects of the procedure, complications, and the contribution of embolization to the surgical management of spinal tumors. In addition, we report our experience with embolization of hypervascular metastases

Preoperative spinal tumor embolization: An institutional experience with Onyx

BackgroundPreoperative embolization has the potential to decrease intraoperative blood loss and facilitate spinal cord decompression and tumor resection. ObjectiveWe report our institutional experience with the embolization of hypervascular extradural spinal tumors with Onyx as well as earlier embolic agents in a series of 28 patients. MethodsA retrospective case review was conducted on patients undergoing preoperative transarterial embolization of a spinal tumor between 1995 and 2012 at our institution. ResultsTwenty-eight patients met the inclusion criteria, with a mean age of 60.6 years. Twenty-eight patients had metastatic tumors. In 14 (50%) patients the metastases were from renal cell carcinomas. Fifty-four vessels were embolized using PVA, NBCA, Onyx, coils, or embospheres. Sixteen patients were treated with Onyx, 6 patients with PVA, 3 patients with embospheres, 2 patients with NBCA, and 3 patients with a combination of embolic agents. The average decrease in tumor blush was 97.8% with Onyx versus 92.7% with the rest of the embolic agents (p=0.08). The estimated blood loss was 1616ml (range 350–5000ml). Blood loss was 750cm3 on average with Onyx versus 1844 with the rest of the embolic agents (p=0.14). The mean length of stay was 16 days. The mortality rate was zero. Pre- and post-operative modified Rankin Score (mRS) did not differ significantly in the series (3.12 versus 3.10, respectively, p=0.9). ConclusionIn our experience, the use of transarterial tumor embolization as an adjunct for spinal surgery is a safe and feasible option.

Mini open tumor resection and percutaneous instrumentation for T11 renal cell carcinoma metastasis

Neural decompression and stabilization belong to the standards of oncologic management of metastatic vertebral lesions, which are at risk of spinal cord compression. Quality of life, tumor associated pain, pathologic fractures and the neurologic status may be improved by surgical treatment [1]. The revised Tokuhashi score [2] represents a common tool, which enables predicting prognosis on a multidisciplinary basis and to decide if conservative treatment or palliative surgery would be adequate, depending on the patient’s pathology and comorbidities. Minimally invasive surgery may enlarge the possibilities of palliative procedures. Cementoplasty has a stabilizing effect at the level of the vertebral body and reduces pain efficiently [3]. This technique can be combined with decompression of the lumbar spine, if facet joints and pedicles remain intact. Minimally invasive transpedicular tumor resection through a tubular retractor, combined with percutaneous instrumentation, has been recently described for unstable compressive lesions [4]. Additionally, metastases of well-vascularized primary tumors, such as renal cell carcinoma, present an intraoperative risk of hemorrhage and require a preoperative transarterial embolization [5, 6]. A limited open approach, focused on the tumor area, may further reduce intraoperative bleeding and operating time, which represents a theoretical advantage with regard to the patient’s morbidity.

Surgical treatment of giant cell tumors of the sacrum and spine combined with pre-operative transarterial embolization

The pre-operative embolization of hypervascular spinal tumors is often performed to decrease intraoperative blood loss and facilitate tumor resection; however, few studies have been published on its effectiveness in giant cell tumors (GCT) of the sacrum and spine. The purpose of the present study was to investigate the value of surgical excision with pre-operative transarterial embolization for GCTs of the sacrum and spine, and to evaluate the follow-up outcomes. A retrospective study was performed on 28 patients with GCTs of the sacrum and spine, who underwent surgical treatment combined with pre-operative transarterial embolization between June 1995 and August 2011. The intraoperative blood loss, transfusion, duration of surgery, treatment, local recurrence, complications, follow-up status and functional outcome were reviewed. The average follow-up period was 86.3 months (range, 12–193 months). All the patients were treated with intralesional resection without any intraoperative shock or fatalities. The average intraoperative level of blood loss was 1,528.6 ml (range, 400–5,800 ml), the average transfusion volume was 1,514.3 ml (range, 400–6,000 ml) and the average duration of surgery was 225.4 min (range, 120–470 min). In total, eight (28.6%) patients developed recurrence and two patients succumbed. A total of eight (28.6%) patients experienced complications and 24 (85.7%) retained normal neurological function. Pre-operative embolization significantly decreases intraoperative blood loss and facilitates the maximal removal of the tumor. Pre-operative embolization followed by intralesional resection is able to achieve satisfactory local control and clinical outcomes. It is an effective technique for excising GCTs of the sacrum and spine.

The role of preoperative transarterial embolization in spinal tumors. A large single-center experience

Background contextPatients with spinal tumors are often referred for preoperative angiography and embolization before surgical resection to minimize intraoperative bleeding. PurposeThe purpose of the present study was to investigate the angiographic appearance of a variety of spinal tumors, assess the safety and efficacy of preoperative embolization in relation to the amount of intraoperative blood loss, and correlate intraoperative tumor histology with the degree of gadolinium enhancement on spinal magnetic resonance imaging (MRI) and tumor vascularity visualized during angiography. Study design/settingRetrospective and single-institution cohort study. Patient sampleOne hundred four patients with spinal tumors referred for preoperative embolization. Outcome measuresEffectiveness of preoperative embolization in relation to intraoperative blood loss and number of transfused packed red blood cell units in perioperative period (72 hours). MethodsFrom 2000 to 2009, 104 patients with spinal tumors underwent 114 spinal angiographies with the intent to embolize feeder vessels before surgery. The effectiveness of embolization was compared with the documented intraoperative blood loss. Angiographic tumor vascularity was graded from 0 (avascular) to 3 (highly vascular). Ninety-four patients had a pre– and post–gadolinium-enhanced MRI of the spine before transarterial embolization. Magnetic resonance imaging vascular enhancement was classified as Grade 3 (avid contrast enhancement), Grade 2 (moderate), or Grade 1 (mild). ResultsTransarterial tumor embolization was angiographically complete in 63 (66%) and partial in 33 procedures (34%). In 18 cases, the target was not deemed suitable for embolization. A limited statistical analysis did not reveal a statistical difference in documented intraoperative blood loss between patients with complete versus partial embolization for the entire cohort or when stratified into renal cell carcinoma (RCC; p=.64), multiple myeloma (p=.28), malignant (p=.17) and benign tumor groups (p=.26). There were no clinical complications associated with embolization. There was poor correlation between MRI enhancement and angiographic vascularity. ConclusionsPreoperative embolization was angiographically effective in most cases. Avid gadolinium enhancement (Grade 3) on MRI was not predictive of hypervascularity on angiography. Furthermore, hypervascularity was not restricted to classically vascular tumors, such as RCC, as it was noted in some patients with breast and prostate cancer. However, with the available numbers, the quality of preoperative embolization did not significantly affect intraoperative blood loss. A future prospective randomized controlled study may be warranted to better characterize the benefits of preoperative embolization for spinal tumors.

CLINICAL OUTCOMES AND ORTHOPEDIC SURGERY FOR BONE METASTASES FROM HEPATOCELLULAR CARCINOMA

Purpose: The aim of the present study was to elucidate the clinical outcomes of hepatocellular carcinoma (HCC) metastases to bone. Methods: The clinical records of 15 patients diagnosed with HCC metastases to bone were retrospectively reviewed. The patients' mean age was 70.8 years. Patients were followed for an average period of 333 days. Clinical features, treatments and outcomes were analyzed. Results: Extrahepatic metastases, except to bone, were detectable in the lymph nodes of three patients (20.0%), the lungs of two patients (13.3%) and the adrenal glands of two patients (13.3%). Radiation therapy was carried out at 31 sites in 13 patients and its efficacy was calculated to be 80.6%. Orthopedic surgery was undertaken at 15 sites in 10 patients. Unexpected mortality due to bleeding occurred suddenly in two patients soon after surgery. Conclusions: Radiation therapy may be the first-choice palliative treatment for bone metastases from HCC. If the condition allows for residual liver function and a coagulative pattern, surgery must be considered for the treatment of some severe pain symptoms, including those caused by pathological fractures of long bones and increased symptoms due to nerve compression caused by spinal metastases. Surgical planning, such as preoperative transarterial embolization or intraoperative cementing, may play an important role in reducing intraoperative bleeding, which can lead to liver failure and death.

Preoperative Embolization of Primary Spinal Aneurysmal Bone Cysts by Direct Percutaneous Intralesional Injection of n-Butyl-2-Cyanoacrylate

Aneurysmal bone cysts (ABCs) are highly vascular lesions often referred for preoperative transarterial embolization. However, accessible arterial pedicles do not always exist. Two cases are presented of pediatric patients with spinal ABCs in which preoperative embolization was performed by percutaneous injection of up to 31 mL of liquid embolic agent (1:7 ratio, n-butyl-2-cyanoacrylate [n-BCA] to ethiodized oil). Total estimated surgical blood loss was 1,000 mL in one case and 3,650 mL in the other case, which occurred during the extensive anterior and posterior approaches required to remove the massive ABCs. Direct percutaneous injection of n-BCA is a technically simple and efficient adjunct to surgical resection with the aim to reduce intraoperative blood loss.

Direct intratumoral embolization of intranasal vascular tumors

Embolization is a well established technique that facilitates the subsequent surgical removal of vascularized tumors such as juvenile angiofibroma. Preoperative transarterial embolization has proven beneficial for decreasing intraoperative blood loss. However, the procedure is often incomplete owing to extensive vascular structure. Direct intratumoral embolization may help overcome this limitation. We report our experience with embolization of nasal vascular tumors by means of direct intratumoral injection of n-butyl cyanoacrylate (NBCA).

Preoperative transarterial Embolisation in bone tumors

Bone tumors include a variety of lesions, both primary and metastatic. The treatment modalities for bone tumors vary with the individual lesion, but in general surgical excision is the treatment of choice with other adjunctive therapies. However, surgery for many bone tumors is complex due to several factors including tumor bulk, vascularity, vicinity to vital structures and potentially inaccessible location of the lesion. Transarterial Embolisation (TAE) is one of the important adjuvant treatment modalities and in some cases it may be the primary and curative treatment. Preoperative TAE has proved to be effective in both primary and metastatic bone tumors. It reduces tumor vascularity and intraoperative blood loss, the need for blood transfusion and associated complications, allows better definition of tissue planes at surgery affording more complete excision, and hence reduced recurrence. Preoperative chemoEmbolisation has also been shown to increase the sensitivity of some tumors to subsequent chemotherapy and radiotherapy. There are several techniques and embolic agents available for this purpose, but the ultimate aim is to achieve tumor devascularization. In this review, we discuss the techniques including the choice of embolic agent, application to individual lesions and potential complications.

Management of Symptomatic Vertebral Hemangioma

Retrospective study. To analyze our experience in the treatment of symptomatic vertebral hemangioma, review the relevant literature, and propose a management algorithm. Hemangioma is one of the commonest benign neoplasms affecting the vertebral column. These usually dormant lesions may become symptomatic by causing pain, neurologic deficit, or both. Several treatment modalities are available in the management of such symptomatic conversion. The clinical and radiographic data of 6 patients diagnosed with symptomatic vertebral hemangioma and treated at our medical center over a period of 10 years were reviewed and analyzed retrospectively. Six patients were diagnosed with symptomatic vertebral hemangioma between 1998 and 2008. The lesions occupied the thoracic, lumbar, or multiple segments. Our patients presented with either simple or radicular back pain. One patient had muscle weakness, 3 revealed sensory impairment, and the remaining 2 were neurologically intact. Four patients underwent preoperative transarterial embolization followed by laminectomy and vertebroplasty of the affected level and 2 patients were treated with vertebroplasty alone. A 35-year-old woman presented during pregnancy. Her clinical course during evaluation was complicated by an acute pulmonary embolic event that necessitated installation of an inferior vena cava filter. All patients had an overall uneventful postoperative course and reported symptomatic relief to varying degrees, at an average follow-up period of 35 months. Symptomatic hemangioma involving the vertebral column may pose a therapeutic challenge, often requiring the active involvement of several disciplines. A review of the relevant literature, however, discloses only few management algorithms for such lesions. The coupling of preoperative transarterial embolization followed by vertebroplasty, with or without surgical decompression depending on the patients' presenting symptoms, is a relatively safe treatment and may offer long-term symptomatic relief in these patients. Other aspects of treatment are further discussed.

Wunderlich's syndrome in spontaneous angiomyolipoma bleeding.

A 57-year-old female presented to the emergency department with progressive right flank pain for 2 days. She denied recent traumatic events. Initial vital signs were stable with blood pressure 125/80 mmHg. Physical examination revealed right flank knocking tenderness. Laboratory data showed leukocytosis 20 180/μL and normal haemoglobin 10.5 g/dL. The routine urine analysis was normal. After clinical evaluation, an abdominal computer tomography (CT) revealed a huge fat-containing tumor with active contrast extravasation and hematoma formation over the right perirenal space (Figure 1A). A diagnosis of renal angiomyolipoma with spontaneous bleeding was made. Transarterial angiography of the right kidney was emergently performed with coil embolization of the hypervascular tumor with intralesional aneurysmal formations (Figure 1B). The patient’s symptoms resolved shortly after embolization and she was scheduled for further renal-sparing surgery. Fig. 1. Renal angiomyolipoma are generally benign mesenchymal hamartoma composed of adipose tissue, tortuous blood vessels and smooth muscle. About 80% of renal angiomyolipoma occurs sporadically and 20% associated with tuberous sclerosis complex [1, 2]. Sporadic angiomyolipoma usually with a solitary nodule in middle-aged women; tuberous sclerosis complex with angiomyolipoma are usually bilateral and multiple, frequently with larger tumor size [2]. Clinical presentations of angiomyolipoma are usually subclinical until tumor size becomes progressively larger with mass effect or tumor rupture. Wunderlich’s syndrome (spontaneous renal hemorrhage) is a rare but potentially life-threatening complication of renal angiomyolipoma in the setting of tumors >4 cm. Clinical manifestations usually include flank pain, a palpable mass, gross hematuria and hypovolemic shock. CT is a good choice of imaging modalities because it is sensitive to demonstrating a fat-containing renal mass with perirenal and retroperitoneal hemorrhage, which is characteristic of Wunderlich’s syndrome due to spontaneous angiomyolipoma rupture. In addition, intralesional aneurysmal formations on the CT scan can lead to a greater possibility of tumor rupture [3]. Optimal treatment plans of angiomyolipoma depend on the tumor size and clinical manifestations. Conservative follow-up with imaging modality is recommended if tumor size is <4 cm in diameter. In acute tumor rupture, urgent transarterial superselective embolization can stop bleeding and save the life of patient. In symptomatic or larger angiomyolipoma with a high risk of bleeding, optimal treatment including elective preoperative transarterial superselective embolization prevention of and sequential renal-sparing surgery [4].

Preoperative Angiography and Transarterial Embolization in the Management of Carotid Body Tumor: A Single-Center, 10-Year Experience

Preoperative Angiography and Transarterial Embolization in the Management of Carotid Body Tumor: A Single-Center, 10-Year Experience

E-041 Combined endovascular embolization and surgical resection of a massive lumbosacral arteriovenous malformation in a patient with Cobb syndrome

Objective and importanceCobb syndrome is a rare condition that includes a cutaneous nevus with an associated spinal vascular lesion at the same dermatome. We present a challenging case of a...

Pre-operative transarterial embolization for treatment of primary sacral tumors

Pre-operative embolization of hypervascular spinal tumors can be helpful in tumour resection; however, few studies have been reported on its effectiveness in sacral tumors. We aimed to investigate the value of surgical excision with pre-operative transarterial embolization for primary sacral tumors and evaluate the long-term follow-up outcomes. Data were obtained from a consecutive series of 60 patients (33 female, 27 male) who had sacral tumors and who, between 1992 and 2007, underwent surgical excision in conjunction with arterial embolization. The evaluation parameters included intraoperative blood loss, transfusion, treatment, local recurrence and complications associated with surgery. All tumor masses were resected without intraoperative shock or death. The mean intraoperative blood loss was 1168.3 mL (range: 200–5700 mL) and the mean transfusion amount was 5.2 units (range: 0–35 units). Radical wide excision was performed on eight patients, marginal excision was conducted for 34 patients and intralesional excision was undertaken for the remaining 18 patients. The mean follow-up period was 75.2 months (range: 15–180 months). Nineteen (31.7%) patients developed local recurrences. Of the patients who had at least the second sacral roots and the unilateral S3 preserved, 33 (84.6%) had normal bladder function and 34 (87.2%) had normal bowel control. Pre-operative arterial embolization may significantly reduce the likelihood of intraoperative hemorrhage, and has the potential to assist surgeons in completing tumor resection and improving the outcomes for these patients.

Surgical management of aggressive vertebral hemangiomas causing spinal cord compression: long-term clinical follow-up of five cases

BackgroundAggressive vertebral hemangiomas causing spinal compression are rare, and there is controversy with regard to treatment. The purpose of this study was to evaluate the clinical results of patients with aggressive vertebral hemangiomas at a mean follow-up of more than 10 years after total excision and discuss the treatment options for the tumors. MethodsWe performed a retrospective review of patients with aggressive vertebral hemangiomas who were treated with total excision. The surgeries were carried out on five patients (average age 47 years). In all five patients, the tumor was in the thoracic spine and was causing myelopathy with extraosseous extension. There were three tumors of type 5 and two of type 6 according to Tomita’s surgical classification of spinal tumors. The tumors were assessed using magnetic resonance imaging (MRI), and the clinical results were evaluated. ResultsAll of the tumors showed low-intensity or low-isointensity signal on T1-weighted MRI. All five patients had a combination of preoperative transarterial embolization and total excision including tumor margin. Total en bloc excisions were performed in two patients. En bloc and piecemeal combined total excisions were performed in two patients. Piecemeal total excision was performed in one patient. Intraoperative blood loss ranged from 1580 to 3400ml (mean 2424ml). There were no perioperative complications. According to the Japanese Orthopaedic Association score, the myelopathy improved after the surgery from 5.3 ± 2.9 to 9.8 ± 1.7 (total of 11 points). None of the patients have had a recurrence at a mean followup of 135.2 months (range 92–163 months). ConclusionsWe performed a combination of preoperative transarterial embolization and total excision for aggressive vertebral hemangiomas with extraosseous extension that were causing spinal cord compression in all five cases. The results in the long-term follow-up have proved satisfactory.