DOI:10.2214/AJR.07.4037
AJR 2008; 191:W240-W247
© American Roentgen Ray Society
Interventional Management of Hypervascular Osseous Metastasis: Role of Embolotherapy Before Orthopedic Tumor Resection and Bone Stabilization
Ralph Kickuth1,
Christian Waldherr1,
Hanno Hoppe1,
Harald M. Bonel1,
Karin Ludwig1,
Martin Beck2 and
Jürgen Triller1
1 Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital,
University of Berne, Freiburgstrasse 20, CH-3010 Berne, Switzerland.
2 Department of Orthopedic Surgery, Inselspital, University of Berne, Berne,
Switzerland.
Received March 28, 2008;
accepted after revision June 27, 2008.
Address correspondence to R. Kickuth
(ralph.kickuth{at}insel.ch).
WEB
This is a Web exclusive article.
Abstract
OBJECTIVE. The purpose of this study was to evaluate, in relation to
intraoperative estimated blood loss (EBL), the effectiveness of preoperative
transcatheter arterial embolization of hypervascular osseous metastatic
lesions before orthopedic resection and stabilization.
MATERIALS AND METHODS. Between June 1987 and November 2007, 22
patients underwent transcatheter arterial embolization of tumors of the long
bone, hip, or vertebrae before resection and stabilization. Osseous metastatic
lesions from renal cell carcinoma, malignant melanoma, leiomyosarcoma, and
prostate cancer were embolized. All patients were treated with a coaxial
catheter technique with polyvinyl alcohol (PVA) particles alone or a
combination of PVA particles and coils. After embolization, each tumor was
angiographically graded according to devascularization (grades 1–3)
based on tumor blush after contrast injection into the main tumor-feeding
arteries.
RESULTS. In patients with complete devascularization (grade 1), mean
EBL was calculated to be 1,119 mL, whereas in patients with partial
embolization (grades 2 and 3) EBL was 1,788 mL and 2,500 mL. With respect to
intraoperative EBL, no significant difference between devascularization grades
was found (p > 0.05). Moderate correlation (r = 0.51,
p = 0.019) was observed between intraoperative EBL and tumor size
before embolization. Only low correlation (r = 0.44, p =
0.046) was found between intraoperative EBL and operating time. Major
complications included transient palsy of the sciatic nerve and gluteal
abscess in one patient.
CONCLUSION. The results of this study support the concept that there
is no statistically significant difference among amounts of intraoperative EBL
with varying degrees of embolization.
Keywords: bone tumor • embolization • orthopedic surgery
Introduction
Pain from skeletal metastasis can be multifactorial. Major causes of
intractable pain include mechanical instability, impending fracture, and
existing pathologic fracture
[1–3].
Orthopedic surgery is generally accepted as the primary management of these
entities [2,
3]. The purpose of surgical
therapy is palliation and improvement of the quality of life remaining for the
patient
[2–4].
These aims are usually reached by relieving pain, preserving the function of
the affected skeletal part, preventing complications, and shortening the
hospital stay. The choice of surgical procedure usually depends on the
localization, number, and size of the skeletal metastatic lesions and the
degree of functional deficit.
The often hypervascular nature of metastatic lesions of the bone can cause
technical difficulties with respect to the extent of surgery and primary
stability for pain relief [2,
3,
5,
6]. Adequate surgical
procedures are associated with substantial blood loss
[2,
3,
7–9].
The resulting high transfusion requirements are frequently complicated by
depletion of clotting factors and by complex acquired coagulopathies, which
cause variation in intraoperative bleeding
[3,
4]. Blood salvage techniques
are contraindicated because of the risk of further dissemination of tumor
cells [10]. Compared with the
amount of information on the effects of preoperative embolization of
hypervascular spinal tumors, few data exist concerning embolization of
hypervascular metastatic lesions of the long bones and hip
[1–4,
11,
12]. Moreover, awareness of
this kind of treatment among oncologic surgeons seems low. The aim of our
study was to assess in relation to intraoperative estimated blood loss (EBL)
the effectiveness of transcatheter arterial embolization (TAE) of
hypervascular metastatic lesions of the bone before orthopedic resection and
stabilization.
Materials and Methods
A retrospective review of the archives of our interventional radiology
department between June 1987 and November 2007 yielded the cases of 22
patients who had consecutively undergone diagnostic angiography and selective
TAE of hypervascular metastatic lesions of the long bones, hip, or vertebrae
for reduction of EBL during orthopedic resection and stabilization. The
patient's demographic and baseline characteristics are presented in
Table 1. The indications for
orthopedic surgery were impending fracture in 13 patients, pathologic fracture
in eight patients, and neurologic deficit due to spinal cord compression in
one patient. The following hypervascular secondary bone tumors were
identified: metastasis from renal cell carcinoma (n = 18), metastasis
from malignant melanoma (n = 1), metastasis from leiomyosarcoma
(n = 1), metastasis from hepatocellular carcinoma (n = 1),
and metastasis from prostate carcinoma (n = 1). Eighteen patients had
a solitary metastatic bone lesion, and four patients had multiple metastatic
lesions. In patients with multiple metastatic lesions, only one selected
lesion was treated.
Orthopedic surgery included curettage, polymethylmethacrylate (PMMA)
insertion, and fixation with a dynamic compression plate in 13 patients; tumor
resection and prosthetic replacement of the humeral or femoral head in four
patients; curettage, PMMA insertion, and fixation with a blade plate in one
patient; curettage, PMMA insertion, insertion of intramedullary rods, and
fixation with a dynamic compression plate in one patient; curettage, PMMA
insertion, and insertion of intramedullary rods in one patient; curettage and
femoral neck osteotomy resulting in a Girdlestone procedure in one patient;
and tumor resection, vertebrectomy, and replacement with a titanium basket and
plate fixation in one patient. In all patients, orthopedic surgery was
performed within 48 hours after embolotherapy. Over the years, two experienced
teams of orthopedic surgeons were involved in the surgical procedures. Primary
preoperative evaluation of the patients included conventional radiography in
20 cases and CT in two cases. All patients were examined and treated as part
of routine care. Informed consent was obtained from all patients before
treatment. Our institution does not require institutional review board
approval for retrospective studies.
Angiographic and Embolization Technique
Local anesthesia was used for all 22 embolization procedures, which were
performed through a contralateral (18 patients) or ipsilateral (four patients)
transfemoral approach with a 4- to 5-French vascular sheath (Radifocus,
Terumo). All emboli zations were performed in our angiography suite. None of
the patients received antibiotics.
In all patients a selective diagnostic arteriogram was obtained to
ascertain the hypervascularity of all bone tumors and to identify the main
feeding arteries and corresponding tumor blush. This selective angiography was
performed with a Cobra-shaped catheter (4- to 5-French C-1, Cook) or a
single-curve catheter (4- to 5-French). Diagnostic catheter maneuvers usually
were performed with a steerable 0.035-inch guidewire (Radifocus, Terumo).
In all 22 patients, TAE was performed with a coaxial 2.7-French (Progreat,
Terumo) or 3-French (Fast Tracker, Target Therapeutics) microcatheter placed
in proximity to the tumor-feeding vessels (Figs.
1A,
1B,
1C,
1D,
1E,
2A,
2B,
2C,
2D,
2E,
3A,
3B,
3C,
3D, and
3E). Fourteen patients
underwent TAE with polyvinyl alcohol (PVA) particles (150–300 µm and
350–500 µm, Contour, Boston Scientific) alone. The particles were
reconstituted with 20 mL of contrast medium per vial to guarantee adequate
visualization and were suspended by agitated mixing between two syringes
before injection. Eight patients underwent embolization with a combination of
PVA particles (150–300 and 350–500 µm) and microcoils. The
coils were either fibered 0.018-inch platinum microcoils (VortX, Boston
Scientific) with a nominal configured diameter of 2 x 3 mm, 2 x 4
mm, or 2 x 5 mm and a stretched length of 22–42 mm or fibered
0.018-inch platinum microcoils (Complex Helical, Boston Scientific) with a
nominal configured diameter of 2 mm and a stretched length of 10 mm.
Microcoils as an additional embolic agent were generally used in vascular
branches originating from the main tumor-feeding artery but not principally
supplying the tumor itself, preventing downstream embolization. Transcatheter
coil embolization was performed with an ultrathin coil pusher wire (Coil
Pusher, Boston Scientific) or, more frequently, by saline injection. In
general, embolic agents were selected on the basis of personal preference,
catheter location, catheter size, and vessel size, as previously recommended
[13]. All embolization
procedures were performed by four interventional radiologists who had
6–20 years of experience with this kind of catheter therapy.
View larger version (111K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A —56-year-old man with osseous metastasis from renal cell
carcinoma. Selective angiogram obtained with diagnostic catheter before
embolization shows pathologic hypervascularity in proximal portion of left
ulna. Hypervascular mass is supplied by small branches of ulnar artery.
|
|
View larger version (188K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B —56-year-old man with osseous metastasis from renal cell
carcinoma. Radiograph depicts osteolytic lesion, pathologic fracture in left
proximal ulna, and selective catheterization of feeding branch of left ulnar
artery.
|
|
View larger version (85K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C —56-year-old man with osseous metastasis from renal cell
carcinoma. Selective angiogram obtained with 2.7-French microcatheter shows
vascularization originating from tumor-feeding vessel during transcatheter
arterial embolization.
|
|
View larger version (109K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1E —56-year-old man with osseous metastasis from renal cell
carcinoma. Radiograph shows results after surgical intervention with
curettage, polymethylmethacrylate insertion, and fixation with dynamic
compression plate.
|
|
View larger version (131K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A —65-year-old man with osseous metastasis from prostate
carcinoma. Angiogram obtained before embolization shows hypervascular tumor
blush of left proximal femur. Tumor-feeding branches arise from deep femoral
artery, medial circumflex artery, and lateral circumflex artery.
|
|
View larger version (111K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B —65-year-old man with osseous metastasis from prostate
carcinoma. Radiograph shows large osteolytic lesion in lesser trochanter of
left femur with extraosseous soft-tissue component, pathologic fracture of
femoral neck, and selective catheterization of feeding branch of left deep
femoral artery.
|
|
View larger version (84K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C —65-year-old man with osseous metastasis from prostate
carcinoma. Selective angiogram obtained with 2.7-French microcatheter shows
vascularization arising from feeding pedicle of deep femoral artery.
|
|
View larger version (152K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A —80-year-old woman with osseous metastasis from malignant
melanoma. Angiogram obtained before embolization shows hypervascular area
resulting from osteolytic lesion of right proximal femur and extremely large
extraosseous soft-tissue component. Tumor-feeding arteries originate directly
from deep femoral artery, medial circumflex artery, and lateral circumflex
artery.
|
|
View larger version (162K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B —80-year-old woman with osseous metastasis from malignant
melanoma. Radiographs show osteolytic lesion of right proximal femur,
pathologic subtrochanteric fracture, and selective catheterization of feeding
branch of right deep femoral artery. Former operative fixation of pathologic
femoral neck fracture is evident.
|
|
View larger version (157K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3C —80-year-old woman with osseous metastasis from malignant
melanoma. Radiographs show osteolytic lesion of right proximal femur,
pathologic subtrochanteric fracture, and selective catheterization of feeding
branch of right deep femoral artery. Former operative fixation of pathologic
femoral neck fracture is evident.
|
|
View larger version (102K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3D —80-year-old woman with osseous metastasis from malignant
melanoma. Postembolization angiogram shows grade 3 devascularization with
almost 50% reduction of tumor blush, especially in caudal aspect.
|
|
View larger version (76K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3E —80-year-old woman with osseous metastasis from malignant
melanoma. Radiograph shows results after orthopedic revision with curettage,
polymethylmethacrylate insertion, and fixation with blade plate.
|
|
Data Evaluation and End Point Definition
Angiograms and angiographic records before and after embolization were
reviewed by three radiologists together to gather information on the technical
outcome and complication rate of TAE. Medical records and surgical notes were
analyzed by an orthopedic surgeon to assign the medical outcome and
complication rate of preoperative embolotherapy. The primary end points of our
study were technical outcome, clinical outcome, side effects, and rates of
minor and major complications.
Technical outcome reflected immediate results and was typically evaluated
with completion angiography. It was determined to be intentional reduction or
cessation of antegrade blood flow to the vascular tumor bed. In this setting,
each embolized osseous metastatic lesion (including the extraosseous
soft-tissue component) was angiographically categorized on the basis of
devascularization (embolization) grade, as in previous studies
[2,
4]. Grade 1 was greater than
75% reduction of tumor blush; grade 2, 50–75% reduction of tumor blush;
and grade 3, less than 50% reduction of tumor blush. Clinical outcome
reflected the effect of embolotherapy on intraoperative EBL. This EBL had
usually been documented in the patients' operative records and charts.
Clinical side effects included symptoms such as fever, pain, and malaise and
were attributed to development of a postembolization syndrome.
Complications of treatment were categorized on the basis of outcome
according to the reporting standards of the Society of Interventional
Radiology [14]. Minor
complications included those necessitating no therapy and having no
consequences (class A) and those necessitating nominal therapy and having no
consequence except overnight admission for observation only (class B). Major
complications included those necessitating minor therapy, that is, less than
48 hours of hospitalization (class C); those necessitating major therapy, that
is, an unplanned increase in the level of care and hospitalization longer than
48 hours (class D); those resulting in permanent adverse sequelae (class E);
and those resulting in death (class F).
Statistical Analysis
Descriptive data were presented as medians with ranges, if appropriate;
categoric data were counts and percentages. Spearman's rank correlation test
was used to describe the relation between tumor size and intraoperative EBL
and between operating time and intraoperative EBL and to predict one variable
from another. Intergroup differences were analyzed with the nonparametric
two-sample Mann-Whitney U test and the nonparametric Kruskal-Wallis
H test for more than two samples. Statistical significance was set at
p < 0.05. Statistical analysis was performed with a specialized
computer algorithm (MedCalc version 6, MedCalc Software).
Results
Technical and Clinical Results
The sex ratio in the study was eight men to three women (p <
0.0004, Mann-Whitney U test). Initial diagnostic angiograms confirmed
the hypervascularity of bone tumors in all patients. Among 22 patients who
underwent preoperative embolotherapy for hypervascular secondary bone tumors,
completion angiography showed grade 1 devascularization in 13 patients (59%),
grade 2 devascularization in eight patients (36%), and grade 3
devascularization in one patient (5%). The average maximal tumor diameter
before embolotherapy was 8.3 ± 5.2 (SD) cm (range, 3–20 cm). The
total number of embolized tumor-feeding vessels was 45. In general, a
statistically significant difference was not found in the number of embolized
vessels for lesions in which grade 1 (median, two vessels) versus grade 2
(median, two vessels) and grade 3 (median, three vessels) devascularization
was achieved (p = 0.38, Kruskal-Wallis H test).
The median intraoperative EBL during orthopedic surgery was 600 mL (range,
200–4,000 mL). In patients with grade 1 devascularization, the median
intraoperative EBL was 500 mL (range, 200–4,000 mL). In patients with a
grade 2 devascularization, the median intraoperative EBL measured 1,475 mL
(range, 350–3,800 mL). In the patient with grade 3 devascularization,
the median intraoperative EBL was 2,500 mL. The median number of units of
packed RBCs transfused to our patients was zero (range, 0–8). A moderate
correlation (r = 0.51, p = 0.019, Spearman's rank
correlation test) was found between intraoperative EBL and tumor size before
embolization. There was no significant correlation between intraoperative EBL
and operating time (r = 0.44, p = 0.046, Spearman's rank
correlation test). Nor was there a significant difference in amounts of EBL
for devascularization grade 1, 2, and 3 lesions (p = 0.22,
Kruskal-Wallis H test); between the intraoperative EBL of men and
that of women (p = 0.08, Mann-Whitney U test); in EBL for
the group younger than 65 years and the group 65 years and older (p
> 0.1, Mann-Whitney U test); or in amounts of EBL according to
location of metastasis (proximal upper extremity vs distal upper extremity vs
proximal lower extremity vs distal lower extremity vs spine vs pelvis)
(p = 0.49, Kruskal-Wallis H test). Side effects associated
with postembolization syndrome did not occur.
Complications
The overall rate of complications was 9% (two cases of complications in 22
patients). The rate of major complications was 4.5% (one case in 22 patients);
that of minor complications also was 4.5%. A major complication categorized as
class D occurred in a patient with renal cell carcinoma who underwent
embolization of an osseous metastasis of the left femur. After complete
occlusion of the left deep femoral artery and superior gluteal artery, palsy
of the sciatic nerve and a gluteal abscess developed. The symptoms of palsy
completely resolved over a period of 3 weeks. However, surgical removal of the
gluteal abscess was necessary to prevent further infection and sepsis. Another
patient, who had malignant melanoma, had a class A minor complication:
temporary spasm of the right deep femoral artery during embolization of an
osseous metastatic lesion of the right femur.
Discussion
Since the pioneering study of Feldman et al.
[15], who initially described
selective TAE as a useful adjunct in the management of selected bone tumors,
there has been increasing interest in this kind of therapy
[16–22].
It is a commonly held opinion
[2,
4,
8] that preoperative TAE of
hypervascular malignant bone tumors is a safe and effective procedure for
reduction of intraoperative EBL and surgical morbidity, even if only partial
devascularization has been achieved. Many reports
[2–4,
11,
18], however, describe a wide
spectrum of technical outcomes, clinical outcomes, and complication rates.
Results of some of the trials emphasized that successful embolization can
decrease intraoperative EBL to approximately 500 mL
[2,
4]. Barton et al.
[11] reported intraoperative
EBL of 500–1,500 mL in patients who had undergone preoperative
embolotherapy; patients who had not undergone TAE had an EBL of
2,000–18,500 mL. In a more recent study, Wirbel et al.
[3] found an average
intraoperative EBL of 1,650 mL for spinal lesions and 2,250 mL for peripheral
pelvic lesions after the patients had undergone TAE.
In our series, we found a threefold to fourfold wider range of EBL than in
the trials by Rowe et al. [1]
and Sun and Lang [2]. This
finding was most likely caused by a higher rate of grades 2 and 3
devascularization. On the one hand, the increased rate of partially embolized
tumors in our study was the result of a careful embolization strategy. In
cases in which tumor-feeding vessels originated directly from a first-order
branch, the embolization approach was performed in a rather conservative
manner to minimize the risk of ischemic symptoms (claudication, critical limb
ischemia, sexual dysfunction, large area of tissue loss). On the other hand,
there was an element of difficulty in cannulating all feeding vessels in the
lesions that were incompletely embolized.
Like other investigators
[2], we did not find a
significantly high correlation between average maximal tumor size and
intraoperative EBL. With respect to the relation between operating time and
quantity of intraoperative EBL, directly comparable information is not
available in the literature, to our knowledge. We also could not calculate a
significantly strong correlation between these two variables.
Some investigators [2,
4] have found that
intraoperative EBL depends on the residual area of tumor blush. They reported
a significantly higher amount of intraoperative blood loss in patients with
partial embolization than in those with complete tumor devascularization. In
contrast, we did not find a significant difference between tumor lesions with
and those without residual tumor blushes. The different procedures performed
in our study could have affected the EBL because plating of a femur, as
opposed to femoral nailing, required opening the area of tumor. Aside from the
surgical procedure, inherent factors such as tumor location and tumor type
might have had great effect on the variation in intraoperative EBL among
cases.
We substantially agree with Manke et al.
[23], who considered
intraoperative EBL dependent on the surgeons' individual technical skills. In
this context, we do not believe that our series was significantly influenced
by the fact that during the time period reviewed, two different teams of
surgeons were involved in tumor resection and stabilization. All those
board-certified surgical colleagues were experienced and highly sophisticated
with regard to orthopedic techniques on hypervascular bone tumors.
In our study, it could be expected that grade 2 and grade 3 lesions would
have greater intraoperative EBL, perhaps necessitating transfusion. Some
patients with grade 1 lesions needed transfusions because they had
tumor-associated sideropenic anemia or elevated intraoperative EBL. It remains
unclear why embolization in two cases appeared to be clinically ineffective
(intraoperative EBL, 3,000 and 4,000 mL) despite good angiographic
results.
Complications and side effects due to preoperative TAE of hypervascular
bone tumors are rare, but a few relevant disadvantages exist
[2,
24]. A postembolization
syndrome with symptoms such as fever, pain, and malaise is a major side
effect. TAE can result in a large zone of tissue loss not expected before
therapy. TAE of adjacent or distant nontargeted vessels, such as the inferior
or superior gluteal artery, may be associated with risk of development of
palsy of the sciatic nerve or of buttock necrosis. Placement of tissue at risk
of ischemia is another complication of TAE that can occur, with its inherent
symptoms such as infection and dramatically increased leukocytosis. Some of
the embolization procedures in our study could have been performed with a
4-French diagnostic catheter alone. Nonetheless, we generally preferred the
coaxial approach to minimize the incidence of dissection, vasospasm, and
errant TAE.
Use of PVA particles has been widely considered
[2,
13,
23] the workhorse of
preoperative TAE of hypervascular osseous metastatic lesions, as was
documented in our trial. The use of coaxial microcatheter systems and PVA
particles may ensure rapid and permanent occlusion of tumor-feeding vessels
with minimized risk of complications
[2]. One should be aware,
however, that the size of PVA particles has to be adjusted to the diameter of
potential collateral vessels and shunts because these entities often are
present in hypervascular malignant bone tumors
[2,
23]. Otherwise, embolization
of nontargeted vessels and ensuing complications can result. In this study,
all of the patients were treated predominantly with medium to large particles
to avoid arterial compromise of the skin and muscle supply. With special
regard to particulate embolic agents, a study
[25] has been conducted to
compare the use of trisacryl gelatin microspheres with the use of PVA
particles in preoperative embolotherapy of bone tumors. The investigators
reported a significant difference between these particulate agents, a minor
amount of intraoperative EBL occurring with the use of trisacryl gelatin
microspheres. They also found that the use of trisacryl gelatin microspheres
was associated with a delay in revascularization of osseous tumors.
The use of coils in the management of hypervascular bone tumors has been
reported [2,
13,
23] to be ineffective because
the rich vascularization of these lesions can open collateral channels within
hours. The combined use of coils and PVA particles has been addressed, but a
significant benefit has not been found as far as TAE of the main tumor feeders
is concerned. However, some authors
[2,
23] have pointed out that
protective coil placement in arteries distal to the origin of tumor feeders or
in vessels arising from the main tumor feeder but not essentially contributing
to the tumor supply may be useful for avoiding unintentional downstream
embolization.
There were two main limitations to our study. First, the sample size was
small, preventing us from generalizing the results. Second, the study was
retrospective and lacked randomization. A prospective randomized trial would
be beneficial for defining the exact value of preoperative embolization
compared with a surgical approach without embolotherapy. Such a trial,
however, would be ethically difficult to design and perform. Owing to the
small number of patients and low statistical power, we consider the results of
our study preliminary. In our clinical practice, we perform this embolization
procedure at the special request of orthopedic surgeons. However, patient
selection is restricted to cases in which the tumor is likely to be violated,
as in fractures, large soft-tissue masses, and curettage.
Our experience with minimally invasive preoperative microcatheter
embolotherapy for hypervascular metastatic lesions of the bone shows that
there is no statistically significant difference in amounts of intraoperative
EBL with varying degrees of embolization. Because of the limitations of this
study, this finding is contradictory to that of previous investigations.
Additional studies that integrate broad multicenter experience into a
treatment strategy with coaxial embolization are desirable for collection of
reliable data on this innovative procedure compared with a surgical approach
without embolotherapy.
References
- Rowe DM, Becker GJ, Rabe FE, et al. Osseous metastases from renal
cell carcinoma: embolization and surgery for restoration of function.
Radiology1984; 150:673
-676[Abstract/Free Full Text]
- Sun S, Lang EV. Bone metastases from renal cell carcinoma:
preoperative embolization. J Vasc Interv Radiol1998; 9:263
-269[Medline]
- Wirbel RJ, Roth R, Schulte M, Kramann B, Mutschler W. Preoperative
embolization in spinal and pelvic metastases. J Orthop
Sci 2005;10:253
-257[Medline]
- Chatziioannou AN, Johnson ME, Pneumaticos SG, Lawrence DD, Carrasco
CH. Preoperative embolization of bone metastases from renal cell carcinoma.
Eur Radiol2000; 10:593
-596[CrossRef][Medline]
- Carpenter PR, Ewing JW, Cook AJ, Kuster AH. Angiographic assessment
and control of potential operative hemorrhage with pathologic fractures
secondary to metastasis. Clin Orthop Relat Res1977; 123:6
-8
- Bowers TA, Murray JA, Charnsangavej S, Soo CS, Chuang VP, Wallace
S. Bone metastases from renal cell carcinoma: the pre-operative use of
transcatheter arterial occlusion. J Bone Joint Surg Am1982; 64:749
-754[Abstract/Free Full Text]
- Olerud C, Jonsson H Jr, Lofberg AM, Lorelius LE, Sjostrom L.
Embolization of spinal metastases reduces perioperative blood loss: 21
patients operated on for renal cell carcinoma. Acta Orthop
Scand 1993;64:9
-12[Medline]
- Gellad FE, Sadato N, Numaguchi Y, Levine AM. Vascular metastatic
lesions of the spine: preoperative embolization.
Radiology1990; 176:683
-686[Abstract/Free Full Text]
- Hess T, Kramann B, Schmidt E, Rupp S. Use of pre-operative vascular
embolization in spinal metastasis resection. Arch Orthop Trauma
Surg 1997;116:279
-282[Medline]
- Capdevila X, Calvet Y, Biboulet P, Biron C, Rubenovitch J, d'Athis
F. Aprotinin decreases blood loss and homologous transfusions in patients
undergoing major orthopedic surgery. Anesthesiology1998; 88:50
-57[CrossRef][Medline]
- Barton PP, Warneck RE, Karnel FJ, Ritschl P, Kramer J, Lechner GL.
Embolization of bone metastases. J Vasc Interv Radiol1996; 7:81
-88[Medline]
- Varma J, Huben RP, Wajsman Z, Pontes JE. Therapeutic embolization
of pelvic metastasis of renal cell carcinoma. J Urol1984; 131:647
-649[Medline]
- Coldwell DM, Stokes KR, Yakes WF. Embolotherapy: agents, clinical
applications, and techniques. RadioGraphics1994; 14:623
-643[Abstract]
- Drooz AT, Lewis CA, Allen TE, et al. Quality improvement guidelines
for percutaneous transcatheter embolization. J Vasc Interv
Radiol 2003;14:S237
-S242[Medline]
- Feldman F, Casarella WJ, Dick HM, Hollander BA. Selective
intraarterial embolization of bone tumors: a useful adjunct in the management
of selected lesions. AJR1975; 123:130
-139[Abstract]
- Roscoe MW, McBroom RJ, Louis ES, Grossmann H, Perrin R.
Preoperative embolization in the treatment of osseous metastases from renal
cell carcinoma. Clin Orthop1989; 238:302
-307[Medline]
- Breslau J, Eskridge JM. Preoperative embolization of spinal tumors.
J Vasc Interv Radiol1995; 6:871
-875[Medline]
- Gorich J, Solymosi L, Hasan I, Sittek H, Majdali R, Reiser M.
Embolization of bone metastases. Radiologe1995; 35:55
-59[Medline]
- Murakami R, Baba Y, Furusawa M, et al. Short communication: the
value of embolization therapy in painful osseous metastases from
hepatocellular carcinomas—comparative study with radiation therapy.
Br J Radiol1996; 69:1042
-1044[Abstract/Free Full Text]
- Smit JW, Vielvoye GJ, Goslings BM. Embolization for vertebral
metastases of follicular thyroid carcinoma. J Clin Endocrinol
Metab 2000;85:989
-994[Abstract/Free Full Text]
- Layalle I, Flandroy P, Trotteur G, Dondelinger RF. Arterial
embolization of bone metastases: is it worthwhile? J Belge
Radiol 1998;81:223
-225[Medline]
- Uemura A, Fujimoto H, Yasuda S, et al. Transcatheter arterial
embolization for bone metastases from hepatocellular carcinoma. Eur
Radiol 2001;11:1457
-1462[Medline]
- Manke C, Bretschneider T, Lenhart M, et al. Spinal metastases from
renal cell carcinoma: effect of preoperative particle embolization on
intraoperative blood loss. Am J Neuroradiol2001; 22:997
-1003[Abstract/Free Full Text]
- Hemingway AP, Allison DJ. Complications of embolization: analysis
of 410 procedures. Radiology1988; 166:669
-672[Abstract/Free Full Text]
- Basile A, Rand T, Lomoschitz F, et al. Trisacryl gelatin
microspheres versus polyvinyl alcohol particles in the preoperative
embolization of bone neoplasms. Cardiovasc Intervent
Radiol 2004;27:495
-502[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
