Preoperative Selective Embolization Research Articles

Selective Arterial Embolization for the Management of Large Multinodular Cervicomediastinal Goiter

In the surgical treatment of thyroid disease, surgery of cervicomediastinal goiters has always been a challenge, due to the high risk of intraoperative and postoperative complications, especially excessive bleeding. Case report Fifty-one-year-old female patient with multiple underlying diseases, presenting a large cervical mass resulting to be a large multinodular cervicomediastinal goiter. Underwent selective arterial embolization of vascular branches supplying irrigation to the mass and later a total thyroidectomy with minimum blood loss during the intraoperative time. Conclusion Even if preoperative selective artery embolization is far from being a routine technique in cervicomediastinal goiter surgery, in selected patients who have many underlying medical problems, very voluminous goiter, high bleeding risk or high intraoperative risk, it can be considered a useful and safe procedure.

Preoperative embolization is necessary for large-volume carotid body tumor (≥ 6670mm3) resection.

To investigate the impact of preoperative embolization (p-TAE) on CBT surgical resection and explore the optimal tumor volume for p-TAE of CBT resection. This retrospective study reviewed 139 surgically excised CBTs. According to Shamblin classification, tumor volumes, and whether to carry out the p-TAE, the patients were classified into different groups. The demographic, clinical features, and the intraoperative and post-operative information about the patients were retrieved and analyzed from the patient records. A total of 139 CBTs was excised in 130 patients. According to the results of subgroup analysis, there were no significant differences in surgical time, blood loss, adverse events (AEs), and the revascularization when compared with non-embolization group (NEG) for type I, II, III, respectively (all p > 0.05) except for the surgical time in type I (p < 0.05). Then the X-tile program was employed and determine the cutoff point (tumor volume = 6670mm3) for tumor volumes and blood loss. The average tumor volume was (29,782.37 vs. 31,345.10mm3, p = 0.65) for embolization group (EG) and NEG. The mean surgical time (208.86 vs. 264.67min, p > 0.05) and intraoperative blood loss (252.78 vs. 430.00mL, p < 0.05) were less, and the incidence of revascularization required (35.56 vs. 52.38%, p > 0.05) and total complications (27.78 vs. 57.14%, p < 0.05) were lower in EG when compared with NEG (tumor volume ≥ 6670 mm3). However, the results were not statistically significant when the tumor size was less than 6670mm3. No surgery-related mortality was observed during the follow-up. Preoperative selective embolization of CBT is an effective and safe adjunct for surgical resection, especially for Shamblin class II and III tumors (≥ 6670mm3).

Retroperitoneoscopic resection with preoperative selective embolization and indocyanine green fluorescence visualization of vessels in kidney cancer

Background. Currently, kidney cancer is considered one of the most common oncological pathologies, accounting for 2–3 % of all cancers. In 2018, the total number of primary renal cell carcinoma patients in Ukraine was 4,805 cases, with 1,878 patients dying from this disease. Surgical treatment is the only way for 68 % of patients with localized kidney cancer. The main question remains unanswered — an effective surgical treatment of patients with localized renal cell carcinoma. Our aim was to study the kidney function parameters in localized kidney cancer after retroperitoneoscopic resection with preoperative selective embolization compared to standard kidney resection using thermal ischemia. Materials and methods. Data of 65 patients with localized kidney cancer who underwent nephron-sparing surgery were analyzed. They were divided into two groups. The first one included 40 people with localized kidney cancer who underwent standard organ-sparing surgery with duration of thermal ischemia of less than 20 minutes. The second group consisted of 25 patients with localized kidney cancer who underwent computed tomography with renal vessels reconstruction in the preoperative stage. Branch of the renal artery that feeds the area of the kidney with the tumor was identified. As a next step, selective embolization was performed. Retroperitoneoscopic resection was carried out the next day with fluorescence imaging in the infrared light using indocyanine green. Results. Analysis of the data shows that renal function after surgery for local cancer in case of retroperitoneoscopic resection with preoperative selective embolization of renal vessels is more functionally suitable compared to kidney resection using thermal ischemia. Conclusions. Our data suggest that superselective X-ray vascular embolization and intraoperative indocyanine green fluorescence in the surgical treatment of localized kidney cancer has significant advantages over the standard method of surgical treatment.

EVALUATION OF MICROSURGERY ON SUPRATENTORIAL MENINGIOMA UNDER SELECTIVE EMBOLIZATION PREOPERATION

Objectives: To evaluate clinical and preclinical characteristics and results of microsurgery of meningioma under preoperative selective embolization. Subjects and methods: A descriptive research on 9 patients with meningioma who experienced selective embolization preoperation and microsurgery in Military Hospital 103 from January 2016 to July 2021. Evaluating the tumor extent of resection by Simpson, surgery result by Ojemann. Results: Clinical characteristics include consciousness disorder 11.1%, increased intracranial pressure 88.9%, epilepsy 33.3%, movement disorder 33.3% often in the parietial-temporal lobe, psychosis 11.1% often in the frontal lobe. 100% of patients under total resection, medium duration was 155.56 ± 33.58 minutes. Blood transfusion was 0.33 ± 0.5 units. None of the patients had surgery complications postoperation. The good result was 100%. Conclusion: Symptomatic meningioma depends on the situation. Preoperative selective embolization enables to decline the surgery duration, blood transfusion, to remove tumor totally, and to have good results post-operation.

RETROPERITONEOSCOPIC RESECTION WITH PREOPERATIVE SELECTIVE EMBOLIZATION AND FLUORESCENCE VISUALIZATION OF VESSELS IN KIDNEY CANCER. ANALYSIS OF FUNCTIONAL RESULTS

Aim of the study: kidney function evaluation in patients with localized renal cancer after retroperitoneoscopic kidney resection with preoperative selective embolization in comparison to standard kidney resection. Materials and methods. A total of 65 patients with localized renal cancer was divided into 2 groups: first – 40 patients who underwent standard renal resection with thermal ischemia (open or laparoscopic), second – 25 patients with retroperitoneoscopic kidney resection, and preoperative selective embolization and indocyanine green (ICG) fluorescent imaging. After 1, 6, and 12 months after the operation, the functional state of the kidneys was examined in all patients by means of determination of the serum creatinine and urea, glomerular filtration rate, creatinine clearance, urinary albumin excretion and imaging (renal ultrasound, contrast-enhanced CT or MRI) was performed. Results. The analysis shows significant benefit in postoperative kidney function after retroperitoneoscopic resection with preoperative vascular embolization and intraoperative ICG imaging. Conclusion. The analysis of the obtained data shows that kidney function after surgery for local kidney cancer in the case of retroperitoneoscopic resection with preoperative selective embolization of renal vessels compared to kidney resection using thermal ischemia is more gentle and therefore more functional for wide implementation. Keywords: local renal cancer, retroperitoneoscopic kidney resection, ICG, selective vascular embolization, functional results.

Cone-Beam CT-Guided Transarterial Tagging of Endophytic Renal Tumors with Indocyanine Green for Robot-Assisted Partial Nephrectomy

PurposeTo evaluate the safety, efficacy, and clinical impact of preoperative cone-beam computed tomography (CT)–guided selective embolization of endophytic renal tumors with the fluorescent dye indocyanine green (ICG) and ethiodized oil in patients undergoing robot-assisted partial nephrectomy (RAPN) using near-infrared fluorescence imaging (NIR-FI). Materials and MethodsPatients with renal endophytic tumors eligible for RAPN and transarterial embolization with ICG and ethiodized oil were prospectively enrolled. Technical success was defined as the completion of the embolization procedure. Radiographic success, defined as ethiodized oil accumulation in the nodule, was classified as poor, moderate, good, or optimal on the basis of postembolization cone-beam CT. Surgical visibility of the tumors during RAPN with the use of NIR-FI was classified as follows: (a) not visible, (b) visible with poorly defined margins, and (c) visible with well-defined margins. ResultsForty-one patients underwent preoperative selective embolization. Technical success was 100%. Ethiodized oil accumulation on cone-beam CT was poor in 2 (4.9%), moderate in 6 (14.6%), good in 25 (61.0%), and optimal in 8 (19.5%) of 41 patients. During RAPN with NIR-FI, tumors were visible with well-defined margins in 26 (63.4%), visible with blurred margins in 14 (34.1%), and not visible in 1 (2.4%) of 41 cases. There were no adverse events following endovascular embolization. ConclusionsPreoperative transarterial superselective embolization of endophytic renal tumors with ICG and ethodized oil in patients undergoing RAPN is safe and effective, allowing accurate intraoperative visualization and resection of endophytic tumors.

Ho:YAG 레이저를 이용하여 제거한 하비갑개에 발생한 동정맥기형 1례

Vascular malformations are rare vascular diseases composed of improperly connected vasculature. Arteriovenous malformations (AVMs), havening direct communication between artery and vein without capillary beds, are rare among all vascular malformations. Most AVMs are found intracranially, extracranial AVMs mostly affect the head and neck area. We report an unusual case of a 52-year-old female who was presenting nasal obstruction and diagnosed with AVM originated from the inferior turbinate as a final pathology. Preoperative selective embolization and complete excision of the tumor is the gold standard to treat AVM due to its rich vascular formation. As Holmium:yttrium-aluminium-garnet laser (Ho:YAG laser) is well-known for photocoagulation, hemostasis, and precise excision of tissue, we performed partial inferior turbinectomy with Ho:YAG laser without preoperative selective embolization. The patient was followed-up for four years and did not presented any other nasal symptoms. By this case, we propose that surgical excision with Ho:YAG laser without preoperative selective embolization is feasible for treatment of small AVM without invasion of adjacent tissue. (J Clinical Otolaryngol 2021;32:281-285)

Lumbar Paraspinal Hemangiopericytoma, An Unusual Location: Surgery with Preoperative Embolization

Background: Lumbar paraspinal hemangiopericytoma is rare. The hemorrhagic nature of the tumor causes problems of hemostasis and makes the resection delicate. We report a rare case of lumbar paraspinal hemangiopericytoma managed with preoperative embolization. Clinical Case: It is about a woman of 31 years, admitted for a large left lumbar paraspinal mass that evolved for 6 years. The clinical exam showed an asymmetry of the left paraspinal muscle. The mass painless was extended from the lumbar region. The neurological exam was normal. MRI showed the left large paraspinal mass tissue. It was extended from lumbar vertebrae, L1 to L4, and measured 100 × 50 × 50 mm. It was an iso-intense signal on T1-weighted with strong enhancement after gadolinium. It was hypervascular and supplied by left intercostal T12, L1, and L2 pedicles. The complete exclusion of the hyper-vascular left paraspinal tumor was obtained after selective embolization of the artery left L1 of the pedicle of the intercostal left L1 and trunks intercostal T12 and L2 left. The total resection of a mass encapsulated was performed. The operative outcome was good. The histology concluded to a hemangiopericytoma. No chemotherapy or radiotherapy was prescribed. After 5 years, the patient was asymptomatic. MRI control confirmed tumor resection with a residue at the level of the left intervertebral foramen L1 - L2. Conclusion: Lumbar paraspinal hemangiopericytoma is an extremely rare tumor. Selective preoperative embolization is recommended before the resection of large tumors to reduce vascular supply. A follow-up extended for these patients is necessary, given the frequency of recurrences.

Therapeutic role of selective preoperative embolization in patients with paraganglomas of head and neck

Background/Aim. Paragongliomas are rare hypervascular neoplasms. The aim of this study was to present the experience in the treatment of paragangliomas using preoperative embolization. Methods. This retrospective cross-sectional study included 10 patients (7 women and 3 men; median age 55 years) with paragangliomas that were embolized before surgery. Results. Three patients had tympanicum paragangliomas, two carotid bodies, three jugular and two jugulare-tympanicum paragangliomas. During the operation, only one out of 10 patients had bleeding which required blood transfusion. This patient received 1,130 mL of blood transfusion due to surgical complication. Conclusion. Adequate preoperative selective embolization of paragangliomas is essential in the preoperative preparation of these patients, because this strategy is feasible with low complication rates.

Selective embolization of lingual artery in transoral robotic surgery for the management of recurrent base of tongue carcinomas

The incidence of oropharyngeal carcinoma has been on the rise in recent decades. About 30% of patients who undergo definitive chemoradiation as the initial treatment present with residual/recurrent disease. In such a situation, surgical salvage either in the form of traditional open surgery or transoral robotic surgery (TORS) remains a viable treatment option. However, the extensive vascular supply of the posterior tongue and tonsillar bed increases the risk of perioperative bleeding, which is a key concern. The article describes the technique of selective pre-operative embolization to reduce the risk of perioperative bleeding and enumerate its advantages in providing a bloodless field during surgery. Prospective study of 5 patients with recurrent or residual midline BOT tumours who underwent TORS after selective lingual artery embolization at our centre. None of the patients had any major perioperative bleeding or post procedural complications. All the patients after TORS had their tongue vascularity preserved with adequate recovery of tongue functions. Selective embolization of the feeder vessels provides a favorable bloodless surgical field without affecting the vascular integrity of the remnant tongue. This added advantage helps restoring the normal oral phase of swallowing.

Glomus Tumor of the Pterygopalatine Fossa: A Rare Case Report.

The pterygopalatine fossa (PPF) is a challenging space and pathological processes in this anatomical space are uncommon. This report presents a case of glomus tumor right PPF in a 65years old female patient who underwent tumor removal by endoscopic transnasal-transmaxillary approach with preoperative selective embolization of the right internal maxillary artery.

Analysis of clinical outcome for adolescent patients undergoing conservative nerve-sparing surgery based on the proposed resection classification for sacral giant cell tumor

The most common of age distribution ranges from second to fourth decade of life and patients with giant cell tumors (GCT) aged less than 18 years is more uncommon. We are aiming to reveal what the conservative nerve-sparing surgery values for adolescent patients with sacral GCT. We retrospectively reviewed 15 adolescent patients with sacral GCT aged <eighteen years, who received the conservative nerve-sparing surgery at our center from 2007 to 2018. Four patients presented with tumor of Campanacci grade II and 11 patients with grade III. According to the location of tumor at the sacrum, we classified the surgical resection of sacral giant cell tumor into three types. In our adolescent cohort, nine had the aortic balloon occlusion and five received the selective arterial embolization. All patients were free of disease and no one had the pulmonary metastasis or died of disease. All five wound complications required the debridement. 6 out of 15 patients had the local recurrence that required surgery treatment. The average time to recurrence after initial surgery in the present adolescent cohort was 22.4 months. Two patients had the surgical site infection and three had the wound dehiscence. One had the femoral artery thrombosis due to the aortic balloon occlusion and received the surgical removal of thrombosis. With the help of preoperative selective embolization and intraoperative aortic balloon occlusion, adolescent patients undergoing conservative nerve-sparing surgery for giant cell tumor of sacrum based on the proposed surgical resection classification have an acceptable clinical outcome and neurologic function.

Distal pancreas-coeliac axis resection with preoperative selective embolization of the coeliac axis: a single high-volume centre experience.

Patients with ductal adenocarcinoma in the body and/or tail of the pancreas with involvement of the common hepatic artery and/or celiac axis have until recently been considered unresectable. In selected cases, distal pancreatectomy (DP) with en bloc celiac axis resection (DP-CAR) may be an option to achieve R0 resection. Patients with tumours in the body and/or tail of the pancreas locally advanced with involvement of the common hepatic artery and/or celiac axis, with no distant metastases, were evaluated for DP-CAR procedures. Preoperative embolization was performed 10-14days prior to surgery to enhance collateral arterial supply for the liver and stomach. A total of 21 patients went through DP-CAR of whom 15 were preoperatively embolized. R0 resection vas achieved in 76% of the patients comparable to our standard distal pancreatectomies. The DP-CAR patients had a significant longer postoperative hospital stay, but no difference in major complications, including pancreatic fistulas compared with our standard distal pancreatectomies. No 30 nor 90days postoperative mortality were recorded. Median survival in patients who underwent DP and DP-CAR procedures was 24.0 and 23.5months, respectively (P > 0.5). Outcomes after DP-CAR are comparable to standard distal pancreatectomies. DP-CAR after preoperative embolization is feasible and may in selected patients be a good option for treating patients with tumours in the body and/or tail of the pancreas with central arterial involvement.

Endovascular Management of Paragangliomas

AbstractBackground: Paragangliomas of head and neck are highly vascular tumors, which coupled their surgical excision with high morbidity. Pre-operative transarterial super selective embolization markedly improved safety of their surgical excision.Patients and Methods: This is a retrospective non-randomized clinical and angiographic study of all ten patients with paragangliomas who undergone pre-operative emboliza-tion in Department of Neurosurgery-Tanta University between 2010 and 2016.Results: The ten patients had 11 paragangliomas. 80% of patients were females. The average age of patients was 47 years. All patients had pain and pulsatile tinnitus at diagnosis. Paragangliomas subtypes comprised 8 temporal, 2 carotid body and one vagale tumors. The average reduction of para-ganglioma vascularity after embolization was 80%.Conclusions: Pre-operative transarterial embolization of head and neck paragangliomas is a very safe and effective adjuvant to surgical excision.

Parasagittal and parafalcine meningiomas: integral strategy for optimizing safety and retrospective review of a single surgeon series

Background: Parafalcine and parasagittal meningiomas present unique challenges for resection. Although maximal safe resection is the primary goal of surgical management for these lesions, venous infarction and eloquent cortical structure damage occur in up to 14% of cases. Therefore, optimal preoperative planning and intraoperative technique is critical.Methods: We retrospectively reviewed a single surgeon’s case series with resection of 58 parafalcine and parasagittal meningiomas. Operative strategy included not crossing the superior sagittal sinus (SSS) during craniotomy, not resecting the falx, use of motor evoked potentials (MEPs) to avoid damage to eloquent brain, and selective use of preoperative embolization.Results: Fifty-eight patients, 45 with parasagittal meningiomas and 13 with parafalcine meningiomas were evaluated. Median age 58.34 years and mean follow-up was 7.7 months. Gross total resection (GTR) was achieved in 51.7% of patients and near-gross total resection rate was 48.3%. Postoperative day one discharge rate was 62.1%. Complication rate was 8.6%, with new postoperative neurologic deficit rate of 5.2%. Tumor recurrence/growth documented on postoperative imaging rate was 3.4%.Conclusions: In our series of parasagittal and parafalcine meningioma resection, we report a 51.7% GTR rate associated with a low complication rate. Techniques to minimize perioperative morbidity include not crossing the SSS on craniotomy, avoiding falx resection, using MEPs, and selective preoperative embolization to optimize the chance of a maximal safe resection. We utilize a strategy of conservative initial tumor resection focused on maximizing the chances of a favorable neurologic outcome, followed as necessary by adjuvant therapies such as radiosurgery and salvage therapies such as laser interstitial thermal therapy, although longer follow-up comparable to that of series with more radical approaches is required to determine if long term outcomes are comparable.

Academic contribution of Masatoshi Makuuchi: a master of hepatobiliary surgery, an example to learn from

The famous professor, Masatoshi Makuuchi was known as the king of the liver surgery. Authors concluded main contributions of Masatoshi Makuuchi by reviewing literatures. (1) He was the first to use intraoperative ultrasonography during liver operations. Furthermore, he pioneered anatomical hepatectomy and ultrasound guided transhepatic cholangiography and cholangial drainage. (2) He was the first to adopted pre-operative selective portal vein embolization (PVE) and hemihepatic blood flow occlusion. (3) He performed the first adult-to-adult living donor liver transplantation (A-ALDLT) worldwide and established the well-known formula to predict standard liver volume. (4) The more laudable achievement is promoting these advanced concepts and techniques to the world, training a large group of contemporary hepatobiliary surgeons and benefiting a great number of patients. Masatoshi Makuuchi is a well-deserved master and a good example for contemporary hepatobiliary surgeons to follow. Key words: Hepatobiliary surgery; Masatoshi Makuuchi; Contributions; Learning

Successful treatment of Neuroblastoma in an adolescent with intra-arterial embolization before surgery

Abstract Introduction Neuroblastoma in the adolescent is characterized by indolent growth and poor outcome. Surgical resection of the tumor is an essential part of the multimodality treatment. Surgical complications depend on the presence of Image Defined Risk Factors (IDRFs). Methods We present an adolescent with pelvic neuroblastoma and epidural compression. To facilitate tumor resection, the patient underwent preoperative selective embolization. Results After selective embolization a subsequent complete resection etraspinal localisation was performed without complication with complete remission after 2 years. Conclusions Preoperative embolization is a safe and feasible technique that can help pediatric surgical oncologist to reduce complications IDRFs-related.

Juvenile 'Perinasal' Angiofibroma.

The extranasopharyngeal angiofibroma is a separate clinical entity but those involving infratemporal fossa and cheek resemble juvenile nasopharyngeal angiofibroma (JNA) and hence have been labelled as juvenile perinasal angiofibroma (JPA) in this paper. This paper presents a 7th case of JPA and attempts to review the world literature on JPA, along with a proposal of staging the disease. A 16year male presented with a painless compressible facial swelling since 7months without any epistaxis or nasal obstruction. Initially a vascular lesion was suspected but JNA without nasal extension was strongly suspected on imaging. A deep trucut biopsy confirmed the histopathology. The vascular enhancement was significant and the tumour was excised through open approach (Weber Fergusson). JPA that can be regarded as a variant of JNA that fails to extend medially. Imaging demonstrates classical JNA findings with a clear nose/nasopharynx. A deep trucut biopsy under control in inpatient settings may sometimes help. JPA presents most commonly in Stage II where an open facial approach preferably following selective preoperative embolization is indicated. Hence with painless compressible (or non-compressible) cheek swelling suspected to be of a vascular etiology, a high degree of clinical suspicion for JPA needs to maintained in order to prevent a misdiagnosis.

Arterio-Venous Malformations of the Nose

The purpose of the present study is to evaluate the vascular malformations of the head and neck. They are uncommon lesions, but some areas have a significant potential for fatality, due to their massive bleeding. The vascular anatomy of the nose carries a high recurrence rate, due to the unique characteristic of the nose, especially if deep vascular connection is present. The present article describes 2 patients of nasal dorsum arteriovenous malformations, both using a combined procedure: preoperative selective embolization, en-bloc tumor resection, and reconstruction with a forehead flap. Two female patients with arterio-venous malformations of the nose were examined, subjected to excision procedure and forehead flap reconstruction. Current treatment requires surgical resection of the nose and in conjunction with adjunctive endovascular embolization; it reduces arterio-venous malformations recurrence. The authors report an endovascular and surgical technique to treat nasal arterio-venous malformations, which permits a complete resection and a reconstruction with a forehead flap. There were no major complications such as recurrent ulceration, infection, postoperative bleeding, or flap failure. All the patients responded positively and satisfactory results were achieved in both female patients. To reduce the recurrence of arterio-venous malformations, the multidisciplinary therapy is mandatory. Recent advances in microsurgery and interventional radiology have greatly improved prognosis for patients with arterio-venous malformations. Therefore, a preoperative selective embolization followed by surgical excision seems to be a good compromise for arterio-venous malformations therapy. The forehead flap, for its characteristics, represents the better choice for nasal reconstruction.

Squamous cell carcinoma of the pterygopalatine fossa - A case report

Abstract The pterygopalatine fossa is an inverted pyramid-shaped space of the viscerocranium, protected by bony structures. Surgical access to this anatomical space is difficult, especially for tumor resection. There are numerous open surgical techniques for accessing this space, but nowadays, minimally-invasive endoscopic approaches are preferred in order to increase postoperative quality of life and reduce postoperative morbidities. The tumors of the pterygopalatine fossa can be benign or malignant, and can occur primarily in the fossa or as secondary extensions from the surrounding regions through the multiple canals and foramina in its walls. Squamous cell carcinomas of this space have been described to appear as extensions from the nasopharynx, the paranasal sinuses or through perineural extension from the cutaneous branches of the maxillary nerve. In this paper the authors present a rare case of squamous cell carcinoma of the pterygopalatine fossa, which was excised in an endoscopic transnasal approach after preoperative selective embolization.