Interventional methods have been applied for the tumor therapy or perioperative methods for operation.For visceral tumors,such as hepatic tumors and renal tumors, interventional methods could help to decrease the tumor size,the blood loss,preserve the function of the organ,and at the same time have little complications[9–10].For bone tumors, interventional methods could also be feasible and safe in reducing the intraoperative blood loss and facilitate tumor resection,especially for tumors with abundant vascular supply[11–12].Previous study has introduced the application of interventional methods in upper extremities,but in very small sample size.To our knowledge, this is the first report that concretely assess the control of blood loss during giant upper extremity tumor resection by interventional methods.
One previous study has indicated that preoperative and therapeutic embolization are feasible in extremities of bone and soft tissue tumors.The blood loss of the scapular Ewing sarcoma is 1800 ml,and the devascularization rate is 70%.In our study,we compared the maximum diameter of the tumor(cm) in different groups.In Group B(without interventional group), the maximum diameter of the tumor(cm) was significant larger than that of the Group A(with interventional group)(12.61 ± 4.47 vs 9.78 ± 3.71,p = 0.031 < 0.05). Although the blood loss(ml) didn’t differ significantly between Group A and Group B(467.93 ± 302.08 vs 1150 ± 1424.15,p = 0.087 > 0.05 ).But the massive bleeding rate in Group A is lower than that in Group B(6.9% vs 46.47%,p = 0.004 < 0.05).And the transfusion of blood plasma(ml) of Group B is also higher than that of Group A(425.33 ± 476.20 vs 425.33 ± 476.20,p = 0.021 < 0.05).Preoperative embolization of primary or metastatic bone tumors is an effective method in shrinking the tumor size and reducing blood loss.
TAE could provide feasible blood control in operations.But,there also exist some problems,such as the impulse intervention of TAE for tumor might not provide longlasting devascularization of the tumor.Not all the tumors could receive the complete percent of TAE,and as time goes by,the revascularization of the tumor might increase.There are also flexible addition of invertional methods,such as the subclavian balloon occlusion.The subclavian balloon has been applied in subclavian artery avulsion following blunt trauma.Subclavian balloon can be feasible to control bleeding and allow an surgery of open repair.In an case of Subclavian artery laceration following clavicle fracture,endovascular balloon was also used while the fixation of the clavicle was completed.In our research,according to the different intervention methods, group A was further broken down into Group C(the combination of the balloon occlusion and TAE,n = 11) and Group D(the TAE group,n = 18).The difference in the amount of blood loss between Group C and Group D(513.64 ± 357.14 vs 440.00 ± 270.36,p = 0.534) was not significant.But the amount of transfusion of RBC(ml) in Group C was significantly higher than that of Group D(458.18 ± 292.22 vs 164.44 ± 224.03,p = 0.005 < 0.05).Because the rate of minors(patient’s age less than 18) in Group C was significantly higher than that in Group D(27.7% vs 0.00%,p = 0.045 < 0.05).And the minors were more intolerable to blood loss and ischemia,so the blood transfusion was more active.
The possible complications accompanied by endovasclular balloon could occur in all stages including positioning, inflation, during occlusion, deflation, and removal of the sheath. We should learn about these complications before we act.To decrease the compliactions,we should try to minimize the occlusion time ,lessen the time the balloon remains in our body.In our study ,we didn’t observe the relative complications associate with the endovascular balloon,such as subclavian artery stenosis, stroke, limb ischemia, spinal cord ischemia in all of the patients.In our study,the balloons were all inserted the day of the surgery, the average balloon occlusion time(min) was 22.73,and the sheath was immediately removed after the surgery was ended.What’s more,the patients in balloon occlusion group were younger than that of placebo group(33.81 ± 20.47 vs 57.89 ± 19.49,p = 0.004 < 0.05) in our study.For senile patients with primary vessel problems, we should be more cautious of the complications of endovasular balloon.Communication with the anesthesia team is of vital importance to guarantee the safety perioperatively.
In patients with fracture,delayed hemorrhage might increase a patient’s perioperative death rate; early embolization intervention might improve the patients’ outcomes[19–20].Shorter doortoembolization time(DTE) time was associated with better clinical outcomes in patients with complex pelvic fracture. For patients with bone tumors,the embolization time before surgery also arouses great interests for researchers.One previous study investigated the difference of embolization time of intraoperative blood loss for renal cell carcinoma bone metastases.The results may suggest that it is beneficial to perform the surgery < 1 day after TAE.The optimal time of embolization has been in debate.Some researchers suggest that the operation should be undertaken as quickly as possible,because there exists the risk of revascularization[23–25].In our research,according to the different pre-operative embolization days, Group D was further broken down into the Group E(the same day of TAE before surgery) and Group F(more than one day of TAE prior to surgery).The blood loss in these two Groups didn’t differ significantly(357.14 ± 229.91 vs 492.73 ± 291.00,p = 0.314).Upon the operation time(min),we didin’t observe significant difference between Group E and Group F(128.57 ± 28.97 vs 154.09 ± 117.06,p = 0.583).Resemblingly,the postoperative ICU admission,the application of vasopressors between these groups were not significantly differential.
The main limitation of our study is its retrospective characteristics. Because subjects were not randomly allocated, selection bias may exist. The number of cases is also small in our study, and this study could not be adequately powered statistically. And the medical intervention (such as the choice of patients to receive TAE or balloon occlusion) cannot be made on a blinded base. As a result, a large multicenter and randomized controlled study is needed to verify the findings.