Veterinary Surgical Oncology. Группа авторов

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Veterinary Surgical Oncology - Группа авторов


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and active (Silber 1998; Meyerson et al. 2002; Tron et al. 2002; Dauerman et al. 2007). Passive closure devices assist or enhance manual compression and do not provide immediate (<5 min) hemostasis (Dauerman et al. 2007). Examples of passive closure devices (devices enhancing manual compression) include patches, wire‐stimulated track thrombosis, and pneumatic pressure devices (Nader et al. 2002; Applegate et al. 2007; Dauerman et al. 2007; Doyle et al. 2007; Jensen et al. 2008). Over the last decade, active closure devices have been used more commonly as compared to passive closure devices (Dauerman et al. 2007). Active closure devices include collagen‐based devices that may or may not have an anchor or suture included, suture alone devices, and staple/clip devices (Dauerman et al. 2007). Further development of active closure devices is being pursued, and it remains to be seen if these devices gain universal acceptance among those performing arteriotomy for IR procedures.

      Vascular Occlusion Agents and Devices

      To perform vascular occlusion via IO methods, a thorough understanding of the occlusive agents is mandatory. Two broad categories, based on the positioning of the agents in the vessels exist: those delivered into the vessel and carried passively to a target vessel (particles and liquids) and those that are positioned at the site where occlusion is needed (coils and balloons) (Kunstlinger et al. 1981; Ginat et al. 2009; Loffroy et al. 2009). The agent chosen depends on the goal of the procedure, and multiple agents may be indicated and used in the same patient.

      Particles

      Collagen sponges, conventional polyvinyl alcohol (PVA), and microspheres are the most commonly used particles (Loffroy et al. 2009). Collagen sponge particles are used for temporary occlusion (Abada and Golzarian 2007). Most studies suggest that recanalization occurs within 14 days (Abada and Golzarian 2007; Loffroy et al. 2009); however, one study found that 78% of cases were recanalized at 3 days (Louail et al. 2006). These sponges likely perform occlusion through physical effects and by enhancing thrombus formation (Abada and Golzarian 2007; Loffroy et al. 2009).

      Conventional or nonspherical PVA particles are available in multiple sizes. These particles cause mechanical occlusion, and the subsequent blood stasis results in biological occlusion (Loffroy et al. 2009). Nonspherical PVA particles have an irregular shape and may aggregate, resulting in a more proximal occlusion; for instance, a third‐order vessel branch may be occluded when a fourth‐order branch occlusion is desired (Siskin et al. 2000; Loffroy et al. 2009). Nonspherical PVA particles are considered permanent vascular occlusion agents (Siskin et al. 2000; Patel and Soulen 2006); however, some reports have described recanalization of vessels that have been occluded with these particles (Siskin et al. 2000; Loffroy et al. 2009).

      The majority of microspheres that are commercially available are made of trisacryl gelatin, PVA, or sodium acrylate/vinyl alcohol copolymer (Patel and Soulen 2006; Loffroy et al. 2009). Microspheres are available in 100–300 μm, 300–500 μm, 500–700 μm, 700–900 μm, and 900–1200 μm (Laurent 2007). Microspheres have several advantages over nonspherical PVA particles. Microspheres can be calibrated (developed with a predetermined size) and tend to reduce blood flow more quickly and reliably than nonspherical PVA (Laurent 2007; Loffroy et al. 2009). Nonspherical PVA particles can have variable behavior after discharge from a catheter, making the placement of these particles less predictable than microspheres (Laurent 2007). Another advantage of microspheres as compared to nonspherical PVA is that they do not result in catheter blockage as they do not aggregate prematurely (Loffroy et al. 2009).

      Improvements in microsphere technology have allowed for even more sophisticated IO techniques. Microspheres with drug‐eluting capabilities are available and allow for delivery of high‐dose chemotherapy directly to a tumor, with minimal systemic effects (Liapi et al. 2007; Martin et al. 2009). Some of the drugs that have been incorporated into microspheres include doxorubicin, oxaliplatin, and irinotecan (Liapi et al. 2007; Kettenbach et al. 2008; Martin et al. 2009).

      Further advancements in microsphere production include the use of microspheres that can be detected on MRIs and CTs and microspheres that can be resorbed in a controlled manner (Laurent 2007). Being able to visualize the location of a microsphere with CT and MRI allows the clinician to determine the final location of the microspheres and the subsequent tumor response based on that location. Resorption of the microsphere may allow these particles to be used for temporary occlusion.

      Liquids

      Coils

      Coils are the most commonly used mechanical embolization device. Most coils are constructed from stainless steel, platinum, or nitinol; threads are often attached to increase thrombogenic potential (Lustberg and Pollak 2006; Valji 2006; Ginat et al. 2009). Coils can be made in a variety of shapes and sizes and are often delivered from a 5 French angiography catheter or 3 French microcatheter (Wojtowycz 1990b; Lustberg and Pollak 2006). A coil should be properly sized to the vessel that is being embolized. A coil that is too large may not fully “coil” and as a result protrude into a feeding vessel (Wojtowycz 1990b). A coil that is too small can migrate distally or proximally, leading to embolization of the wrong vessel (Valji 2006). Coils are generally used in the embolization of nononcologic diseases such as arteriovenous fistulas and traumatic bleeds; however, reports of coils for the preoperative embolization or definitive treatment of renal, biliary, and hepatic neoplasia exist (Madoff et al. 2003; Munro et al. 2003; Schwartz et al. 2006; Maxwell et al. 2007). Indications for renal embolization may include preoperative infarction, treatment of metastatic renal neoplasia, nonresectable renal neoplasia, and patients who elect not to undergo radical excision (Munro et al. 2003; Schwartz et al. 2006; Maxwell et al. 2007).

      Balloons

      Balloons can be used for vascular occlusion in both a temporary (nondetachable) and a permanent (detachable) fashion. Temporary occlusion or partial occlusion with a nondetachable balloon may be beneficial when delivering particulate embolic agents (Greenfield et al. 1978). The balloon can be used to decrease the rate of blood flow to prevent unwanted occlusion at a distal site (Greenfield et al. 1978). The use of detachable balloons as a permanent vascular occlusion device has fallen out of favor, as newer permanent vascular occlusion agents have developed (Lustberg and Pollak 2006).

      Stents

      Vascular and nonvascular stents have revolutionized


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