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Intraarterial procedures for the musculoskeletal system
Key points
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Intraarterial procedures are useful for pain palliation, local disease control and as an adjunct to a planned surgical intervention.
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Meticulous angiographic technique and careful monitoring of the patient’s neurologic status is essential for preventing complications during embolization of tumors in the spine.
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Specific strategies for embolization of tumors in the spine are discussed.
Background
The arterial system provides an extensive route of access to tumors of the musculoskeletal system, allowing for the precise delivery of embolic agents or antineoplastic chemotherapy. This chapter reviews how intraarterial procedures can be used as a tool for pain palliation, local disease control, and as an adjunct to support surgical interventions.
Patient selection
Patients with primary or secondary musculoskeletal neoplasms often receive care from a multidisciplinary team of physicians, consisting of medical oncologists, orthopedic surgeons, radiation oncologists, and interventional radiologists, who make the collective decision to incorporate the use of intraarterial (IA) therapy. Evaluation of the patient in a clinic setting is essential for providing the patient with education regarding the potential risks and benefits of the procedure. A complete history and physical examination is necessary to document symptoms and their severity and to assess baseline physical function. The use of subjective pain assessment scales (Brief Pain Inventory or Memorial Pain Assessment Card) and the quantification of narcotic medications to a morphine-equivalent dose can be useful tools for determining treatment efficacy in follow-up. Patients with mild pain, <4 on a 10-point scale, usually do not experience significant pain relief following intervention and may not be appropriate candidates for arterial embolization. Patients who undergo a procedure for pain palliation should be counseled on the expected onset, degree, and duration of symptom relief. These patients require close clinical follow-up after the procedure to determine clinical effectiveness. Repeat embolizations may be indicated if pain symptoms recur or develop in a new location.
The diagnostic cross-sectional imaging must be reviewed for procedural planning. Routine laboratory values including coagulation studies and serum creatinine must be evaluated. Normal cardiac and renal function is required for the administration of chemotherapeutic agents. Patients with uncorrectable coagulopathy, renal insufficiency, severe allergic reaction contrast media, or severe atherosclerotic disease may not be candidates for angiography. ,
Technique
Intraarterial procedures are typically performed under monitored, moderate sedation using a combination of fentanyl and midazolam. Adequate hydration is recommended prior to angiography as the use of significant amounts of contrast media may be required. The placement of a urinary catheter may be helpful for monitoring urine output during the procedure and in the postoperative recovery period. Antibiotic prophylaxis is not routinely given.
Intraarterial infusion catheter placement for limb infusion
After arterial access is achieved using Seldinger’s technique, a guiding 4-F or 5-F catheter is directed into the main arterial trunk supplying the tumor. This is usually the common femoral artery for lower extremity lesions and the axillary artery for upper extremity lesions. Image acquisition during angiography should be performed in at least two different projections (anterior and lateral or oblique projections) to allow for the adequate evaluation of the arterial supply to the entire lesion. Angiography should be performed using a power injector to deliver contrast at 3 to 5 mL per second for a total volume of 12–20 mL. Image projections and contrast injection rates should be documented so that subsequent infusion sessions can use the same parameters, allowing for accurate assessment of tumor response during treatment.
Ideally, the catheter should be positioned to deliver the chemotherapy to the entire tumor while minimizing the exposure of uninvolved tissues. Once the catheter position has been optimized, an infusion wire (0.035 in. diameter, 145 cm length) with either a 6- or 12-cm working tip is inserted coaxially through the guide catheter. A longer working tip length is helpful in cases where the catheter must be placed to cross an arterial bifurcation point. For example, if a lesion derives supply from both the deep femoral and superficial femoral arteries, the working tip of the infusion wire should be placed in the deep femoral artery and extend back into the common femoral artery to ensure that chemotherapy is delivered through all arteries supplying the lesion. The infusion wire may be advanced through the guide catheter to the appropriate location in the artery; however, when feasible, a pull-back technique, where the guide catheter is retracted to uncover the infusion wire, should be used to minimize the risk of intimal injury. Following infusion wire placement, contrast injection is performed to verify the appropriate placement.
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