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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3733_Библиотеки_им_академика_М_И_Перельмана.pdf
Hemangiopericytoma
Previously termed angioblastic meningiomas, hemangiopericytomas are rare,
smooth muscle pericyte cell–derived tumors found around meningeal
capillaries. Angiographically, these tumors are characterized by large arterial
pedicles with many tiny corkscrew-like feeding vessels entering the tumor.
The vascular stain is intense and fluffy with lingering contrast in venous
channels. The techniques for the embolization of hemangiopericytomas
parallel those of meningiomas.
53
Hemangioblastoma
Hemangioblastomas are benign vascular tumors typically found during
infancy that occur predominantly in the spinal cord and cerebellum.
Cerebellar hemangioblastomas are also one of the most common posterior
fossa primary central nervous system tumors found in adults. Cerebellar
hemangioblastomas derive most of their blood supply from the cerebellar
arteries (as opposed to the external carotid circulation) as they are intra-axial
in location. Meningeal, tentorial, and vertebral arteries may supply additional
blood.53 Hemangioblastomas typically display irregular vessels with
intensely staining nodules exhibiting homogeneous or mottled appearance on
angiography.
Preoperative embolization has been very successful in reducing
intraoperative blood loss during hemangioblastoma surgery.54 Reduced blood
loss and improved outcomes were reported in tumors that had almost
complete embolization. However, partial embolization resulted in increased
transfusions and more operative complications in some cases.
55
Hemangioblastomas less than or equal to 1.5 cm do not typically warrant
preoperative embolization as the procedural risks can outweigh those of
bleeding during the surgical resection.56 Embolization with particles greater
than 150 µm or liquid NBCA may be safest.
57
POTENTIAL COMPLICATIONS
Both major and minor complications can occur during embolization of
vascular tumors of the head and neck. Major complications may include
cranial nerve palsy, skin or mucosal tissue necrosis, stroke, intracranial
hemorrhage, death, inadvertent embolization of pulmonary vasculature, and
contrast-induced nephropathy.
23
A recent meningioma embolization literature review identified 36
reports published between 1990 and 2011, including 459 patients who
underwent meningioma embolization. Of these, 21 patients (4.6%) had
complications related to embolization and 3 experienced a major
complication or death (0.7%).58 Several studies demonstrating even higher
complication rates were eliminated from the analysis due to strict exclusion
criteria. One excluded study evaluated 167 patients with skull base
meningiomas. The authors documented an immediate postembolization
complication rate of 21.6%, with 9% of patients sustaining permanent
disability.
59
Hemorrhagic complications may occur due to mechanical injury of the
feeding artery by the microcatheter and wires or upon catheter retrieval when
using liquid embolics. Hemorrhagic complications are also thought to occur
in higher frequency when substantial devascularization of the tumor results in
significant necrosis. This risk may be exacerbated by using very small
particles that penetrate deep into the tumor bed.5 Other theories suggest that
compromised venous outflow may increase the risk of hemorrhage in highflow tumors.
25,60,61
Complication Avoidance
Reflux of small particles or liquid material may occur even during the most
precise and careful procedure. Several steps may be taken to reduce this risk.
Catheters should be placed distal to the origin of vessels that need to be
preserved. Particle size should be considered carefully for controlled infusion
as smaller particles are more likely to flow around the catheter. Balloon
catheters may be deployed before delivery of embolic material to prevent or
reduce the amount of refluxed substance.15 Additionally, care should be taken
to avoid proximal rupture of the microcatheter. Proximal rupture may allow
particles to enter and occlude vessels not intended for embolization.
6
Ischemia of the vasa nervorum and resultant cranial nerve palsies can
occur due to reflux of embolic material or penetration of unknown
anastomoses. For example, delivery of embolic material into the stylomastoid
branch of the occipital artery may result in facial nerve palsy. This happens
most frequently with liquid agents but has occurred with PVA particles as
well.30 Careful and thorough angiography of targeted, contralateral, and
nearby vessels before embolic infusion can reveal possible unexpected
anastomoses and aberrant vascular architecture. If a concern for losing blood
supply to cranial nerves exists, provocative testing using lidocaine may be
used.62 The appearance of a new neurologic deficit during testing indicates
the possibility of cranial nerve palsy following embolization. Repositioning
of the microcatheter, as close to the tumor bed as possible, will decrease the
likelihood of obstructing the blood supply to normal tissues.
15
Minor Complications
Common minor complications include arterial access site issues such as
hematoma formation, localized pain, and fever. Transient headache or
temporofacial pain is the most common complication observed after
embolization.16 This can be caused by tumor swelling or, in the case of
intracranial tumors, irritation of the meninges.3 Pain is typically managed
with analgesics.15 Preoperative steroids may limit edema and reduce the
likelihood of resultant complications.30 Dexamethasone 10 mg can be given
intravenously during preoperative assessment before the embolization
procedure. If the tumor is large and a significant amount of embolization has
been achieved, then continuing the dexamethasone at 4 mg every 6 to 8 hours
(intravenous or oral) is advisable. A relatively rapid taper over the next 10 to
14 days is then prescribed. Bradycardia can develop after manipulation of the
branches of the ECA, and sometimes the internal maxillary artery, which can
evoke the trigeminocardiac reflex.
63
Tumor-Specific Complications
One important potential complication specific to catecholamine-secreting
paragangliomas is a life-threatening vasomotor attack.64 If a paraganglioma
of this type is discovered, α-antagonist agents should be used instead of βantagonists, which are contraindicated.6 Carotid sinus syndrome is another
serious complication that can occur after carotid body tumor embolization.
65
In addition, embolization of a jugular paraganglioma has reportedly caused
hypoglossal nerve palsy.66 Accurate preoperative diagnosis and assessment
of paragangliomas can help in preparing for and anticipating potential
hemodynamic instability.
TIPS AND TRICKS
• In addition to bilateral selective catheter angiography of the external
and internal carotid arteries, superselective catheterization of the
external carotid branches is useful to reveal dangerous anastomoses.
• Balloon occlusion testing during catheter angiography can determine
if carotid sacrifice is an option during surgical resection of some
tumors.
• DPT for embolization may be the only option for vascular tumors
with impossible endovascular access.
• Eighty percent reduction of tumor blush following embolization
should be the minimum goal.
• Provocative testing of targeted vasculature with Amytal (grey matter)
and lidocaine (white matter) can help predict cranial nerve palsy and
other neurologic deficit that could be at risk during embolization. As a
result, embolization under conscious sedation where neurologic
examination can be performed should be considered.
• The goals of preoperative embolization should be discussed
extensively with the surgeon.
• Balloon-augmented or protected embolization can help prevent
complications and negate the risks associated with high-flow
shunting.
• Great care should be taken in selecting the embolic agent. The
experience of the operator with the agent may be the most critical
factor.
• Particles should always be mixed with contrast agent to allow for
visualization at the time of injection.
• Sizing of particles during particle embolization is extremely
important. Small particles (45–150-µm diameter) may pose an
increased risk of complications. Particle diameters ranging from 150
to 350 µm may be optimal, except in high-flow shunting where larger
particles may be necessary.
• Particles should be injected with the flow of the blood and not pushed
against resistance. This will help avoid traversing through dangerous
anastomoses or reaching small terminal vessels that supply cranial
nerves.
• If Onyx is used for embolization, the tumor surgeon should be
notified that sparks can be generated with use of the Bovie monopolar
cautery.
• Coils can be used to occlude a dangerous anastomotic channel,
allowing preferential embolization of the target vessel without reflux
into the dangerous anastomosis.
• The embolization catheter should be placed as distal as possible in the
vessel feeding the tumor and must be distal to the origin of vessels
that need preservation.
• Close clinical surveillance postembolization is important to rapidly
identify any major procedure-related complications. Rapid
identification and treatment of these types of complications can
drastically improve patient outcome.
CONCLUSION
In conclusion, the outcome of preoperative embolization for vascular tumors
of the head and neck depends on many factors, including the type and
characteristics of the tumor, the location of the tumor, the vascular
architecture of the patient, the technique implemented, the embolic material
chosen, and the knowledge and experience of the operator. Careful
consideration of all of these factors along with a thorough and thoughtful
workup ensures the best chance of success.
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