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Minici R, Guzzardi G, Venturini M, Fontana F, Coppola A, Spinetta M, Piacentino F, Pingitore A, Serra R, Costa D, Ielapi N, Guerriero P, Apollonio B, Santoro R, Mgjr Research Team, Brunese L, Laganà D. Transcatheter Arterial Embolization (TAE) of Cancer-Related Bleeding. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1323. [PMID: 37512135 PMCID: PMC10383256 DOI: 10.3390/medicina59071323] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/17/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: Roughly 10% of cancer patients experience an episode of bleeding. The bleeding severity can range from occasional trivial bleeds to major bleeding. The treatment for the bleeding may vary, depending on the clinical condition and anatomical site, and may include various strategies, among which TAE is a cornerstone of major bleeding management. However, the existing literature on tumor hemorrhages is inconsistent. The objective of this multicenter retrospective cohort study was to evaluate the effectiveness and safety of arterial embolization in the treatment of tumor hemorrhages in patients with solid cancers. Materials and Methods: The data for patients with solid cancers undergoing TAE for the management of tumor hemorrhages from January 2020 to May 2023 were gathered. Results: A total of 92 patients with cancer-related bleeding were treated between January 2020 and May 2023. No bleeding was detected by X-ray angiography (XA) in 12 (13%) cases; therefore, a blind embolization was performed. The most common bleeding site was the liver (21.7%). A total of 66 tumor hemorrhages were spontaneous. The most commonly used embolic agent was polyvinyl alcohol (PVA) particles (30.4%). Technical success was achieved in 82 (89.1%) cases, with an 84.8% clinical success rate related to 14 cases of rebleeding. Proximal embolization was performed for 19 (20.7%) patients. Complications were recorded for 10 (10.9%) patients. The 30-day bleeding-related mortality was 15.2%. The technical success, clinical success, proximal embolization rate, and 30-day rebleeding were worse in the subset of patients undergoing TAE with coils. Conclusions: Transcatheter arterial embolization (TAE) represents a viable and potentially life-saving therapeutic approach in the management of tumor hemorrhages, demonstrating a notable effectiveness and safety. The TAE of bleeding tumors using coils resulted in a higher rate of non-superselective proximal embolization, with a trend toward lower clinical success rates and higher rebleeding episodes.
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Affiliation(s)
- Roberto Minici
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Giuseppe Guzzardi
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy
- School of Medicine and Surgery, Insubria University, 21100 Varese, Italy
| | - Federico Fontana
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy
- School of Medicine and Surgery, Insubria University, 21100 Varese, Italy
| | - Andrea Coppola
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy
| | - Marco Spinetta
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Filippo Piacentino
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy
| | - Armando Pingitore
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Raffaele Serra
- Vascular Surgery Unit, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Davide Costa
- Department of Law, Economics and Sociology, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
| | - Nicola Ielapi
- Department of Public Health and Infectious Disease, Sapienza University of Rome, 00185 Rome, Italy
| | - Pasquale Guerriero
- Radiology Unit, Santobono-Pausilipon Hospital, 80129 Naples, Italy
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy
| | | | - Rita Santoro
- Haemophilia and Thrombosis Center, Dulbecco University Hospital, 88100 Catanzaro, Italy
| | | | - Luca Brunese
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy
- Scientific Committee of the Italian National Institute of Health (Istituto Superiore di Sanità, ISS), 00161 Rome, Italy
| | - Domenico Laganà
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
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Abstract
Ischemic postconditioning initially referred to a stuttering reperfusion performed immediately after reperfusion, for preventing ischemia/reperfusion injury in both myocardial and cerebral infarction. It has evolved into a concept that can be induced by a broad range of stimuli or triggers, and may even be performed as late as 6 h after focal ischemia and 2 days after transient global ischemia. The concept is thought to be derived from ischemic preconditioning or partial/gradual reperfusion, but in fact the first experiment for postconditioning was carried out much earlier than that of preconditioning or partial/gradual reperfusion, in the research on myocardial ischemia. This review first examines the protective effects and parameters of postconditioning in various cerebral ischemic models. Thereafter, it provides insights into the protective mechanisms of postconditioning associated with reperfusion injury and the Akt, mitogen-activated protein kinase (MAPK), protein kinase C (PKC), and ATP-sensitive K+ (K(ATP)) channel cell signaling pathways. Finally, some open issues and future challenges regarding clinical translation of postconditioning are discussed.
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Affiliation(s)
- Heng Zhao
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305-5327, USA.
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Ren C, Gao X, Niu G, Yan Z, Chen X, Zhao H. Delayed postconditioning protects against focal ischemic brain injury in rats. PLoS One 2008; 3:e3851. [PMID: 19066627 PMCID: PMC2588536 DOI: 10.1371/journal.pone.0003851] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Accepted: 11/05/2008] [Indexed: 12/03/2022] Open
Abstract
Background We and others have reported that rapid ischemic postconditioning, interrupting early reperfusion after stroke, reduces infarction in rats. However, its extremely short therapeutic time windows, from a few seconds to minutes after reperfusion, may hinder its clinical translation. Thus, in this study we explored if delayed postconditioning, which is conducted a few hours after reperfusion, offers protection against stroke. Methods and Results Focal ischemia was generated by 30 min occlusion of bilateral common carotid artery (CCA) combined with permanent occlusion of middle cerebral artery (MCA); delayed postconditioning was performed by repetitive, brief occlusion and release of the bilateral CCAs, or of the ipsilateral CCA alone. As a result, delayed postconditioning performed at 3h and 6h after stroke robustly reduced infarct size, with the strongest protection achieved by delayed postconditioning with 6 cycles of 15 min occlusion/15 min release of the ipsilateral CCA executed from 6h. We found that this delayed postconditioning provided long-term protection for up to two months by reducing infarction and improving outcomes of the behavioral tests; it also attenuated reduction in 2-[18F]-fluoro-2-deoxy-D-glucose (FDG)-uptake therefore improving metabolism, and reduced edema and blood brain barrier leakage. Reperfusion in ischemic stroke patients is usually achieved by tissue plasminogen activator (tPA) application, however, t-PA's side effect may worsen ischemic injury. Thus, we tested whether delayed postconditioning counteracts the exacerbating effect of t-PA. The results showed that delayed postconditioning mitigated the worsening effect of t-PA on infarction. Conclusion Delayed postconditioning reduced ischemic injury after focal ischemia, which opens a new research avenue for stroke therapy and its underlying protective mechanisms.
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Affiliation(s)
- Chuancheng Ren
- Department of Neurosurgery, Stanford University, Stanford, California, United States of America
- Department of Neurology, Shanghai No. 5 Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Xuwen Gao
- Department of Neurosurgery, Stanford University, Stanford, California, United States of America
| | - Gang Niu
- Department of Radiology, Stanford University, Stanford, California, United States of America
| | - Zhimin Yan
- Department of Neurosurgery, Stanford University, Stanford, California, United States of America
| | - Xiaoyuan Chen
- Department of Radiology, Stanford University, Stanford, California, United States of America
| | - Heng Zhao
- Department of Neurosurgery, Stanford University, Stanford, California, United States of America
- * E-mail:
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Gao X, Ren C, Zhao H. Protective effects of ischemic postconditioning compared with gradual reperfusion or preconditioning. J Neurosci Res 2008; 86:2505-11. [PMID: 18438944 DOI: 10.1002/jnr.21703] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We examined the temporal factors of postconditioning, assessed whether gradual reperfusion reduces infarcts, and compared postconditioning's protection with that of both rapid and delayed preconditioning. Focal ischemia was generated by permanent occlusion of the left distal middle cerebral artery (dMCA) combined with 30 min of occlusion of both common carotid arteries (CCA) in rats. Postconditioning was performed by repetitive brief release and occlusion of CCA after 30 min of CCA occlusion. Gradual reperfusion was generated by controlled release of the bilateral CCA. We confirmed that postconditioning disrupted the early reperfusion but improved cerebral blood flow (CBF) thereafter. Postconditioning with three cycles, but not with 10 cycles, of 30 sec CCA release and 10 sec CCA occlusion (30s/10s) reduced infarction measured at 2 days after stroke. In addition, postconditioning with 10 cycles, but not with three cycles, of 10s/10s reduced infarction but it lost protection when initiated at 3 min after reperfusion. In addition, gradual reperfusion also reduced infarction. Moreover, both rapid and delayed preconditioning conducted 60 min and 3 days before stroke reduced infarct sizes. However, no additional protection was detected when postconditioning was combined with either rapid or delayed preconditioning. In conclusion, gradual reperfusion reduced infarction; postconditioning's protection depended on the number of cycles and duration of each cycle of reperfusion and occlusion and the onset time of postconditioning; postconditioning's protection was comparable to that of rapid preconditioning but not as robust as that of delayed preconditioning.
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Affiliation(s)
- Xuwen Gao
- Department of Neurosurgery, Stanford University, Stanford, California 94305-5327, USA
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Upile T, Triaridis S, Kirkland P, Archer D, Searle A, Irving C, Rhys Evans P. The management of carotid artery rupture. Eur Arch Otorhinolaryngol 2005; 262:555-60. [PMID: 15772844 DOI: 10.1007/s00405-004-0775-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2003] [Accepted: 01/23/2004] [Indexed: 11/30/2022]
Abstract
Carotid artery rupture is fortunately an uncommon complication of head and neck cancer treatment. Eleven episodes of carotid artery rupture following irradiation and major head and neck resection were identified over a 6-year period. We review our experience and discuss the predisposing factors that can cause this complication, important aspects of management and outcome. During this 6-year period, 11 episodes of carotid artery rupture were treated in our unit. All patients had received prior irradiation (more than 60 Gy) and undergone a major surgical resection or resections. The average age was 59 years; all patients had a salivary fistula, local infection and a manifest 'herald bleed' just before their major carotid artery rupture. These patients were resuscitated, taken to theatre and the neck explored, with control of the vessel and debridement of necrotic tissue. Soft tissue coverage was in the form of a flap. Many of the factors predisposing to carotid artery rupture can be ameliorated or treated early in order to avoid this complication. Early and aggressive nutritional support together with correction of haematological abnormalities promote wound healing and prevent tissue breakdown. The detection and treatment of infection also reduces fistula formation and wound compromise. We present our protocol for the early, aggressive management of these patients with carotid artery rupture.
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Affiliation(s)
- Tao Upile
- Department of Head and Neck Surgery, Head and Neck Unit, The Royal Marsden Hospital, London, SW3 6JJ, UK
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Abstract
Bleeding occurs in up to 10% of patients with advanced cancer. It can present in many different ways. This article provides a qualitative review of treatment options available to manage visible bleeding. Local modalities, such as hemostatic agents and dressings, radiotherapy, endoscopic ligation and coagulation, and transcutaneous arterial embolization, are reviewed in the context of advanced cancer, as are systemic treatments such as vitamin K, vasopressin/desmopressin, octreotide/somatostatin, antifibrinolytic agents (tranexamic acid and aminocaproic acid), and blood products. Considerations at the end of life are described.
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Affiliation(s)
- Jose Pereira
- Department of Oncology, University of Calgary, Palliative Care Office, Room 710, South Tower, Foothills Medical Centre, 1403-29th Avenue NW, Calgary, Alberta, T2N 2T9, Canada.
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Machens A, Dralle H. Mycotic aneurysm of common carotid artery induced by Staphylococcus aureus infection after cervical reoperation. World J Surg 2001; 25:1113-6. [PMID: 11571944 DOI: 10.1007/bf03215856] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The objective of this study was to define a novel type of mycotic aneurysm of the carotid artery arising after cervical reoperation. We retrospectively analyzed all staphylococcal mycotic aneurysms of the common carotid artery. These aneurysms had developed after reoperative thyroid or parathyroid surgery, including resection of the central lymph node compartment and cervical reexploration. Mycotic aneurysms were found in three patients, with an incidence of 0.77% (2/261) and 0.62% (1/161) for thyroid and parathyroid reoperations, respectively. Postoperatively, a lymphatic fistula and cervical hematoma emerged in all patients, as did cervical wound infections on days 3, 4, and 6. Deep wound infections were noted on surgical revision. Cultures grew exclusively Staphylococcus aureus, which was resistant to methicillin (MRSA) in one patient. Mycotic aneurysms were identified 1 week after cervical reoperation. One aneurysm was discovered incidentally on planned lavage. The other two aneurysms presented as severe arterial hemorrhages, resulting in exsanguination in one patient. The other two patients had their aneurysms replaced by saphenous venous autografts. There seems to be accelerated arterial media destruction with formation of mycotic aneurysms in staphylococcal wound infections after cervical reoperation. It is important to recognize this novel type of mycotic aneurysm, as it must be repaired immediately to anticipate imminent rupture.
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Affiliation(s)
- A Machens
- Department of General Surgery, Martin Luther University, Halle-Wittenberg, Ernst-Grube-Strasse 40, D-06097 Halle/Saale, Germany.
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