Management of patients with bone metastasis is complex and should include different specialties. Goals of therapy should be identified for each individual patient prior to the start of treatment. Preoperative embolization has generally been considered a safe and effective means of reducing intraoperative blood loss with recent studies and advances in technique reported. Update on indications, contraindications, technique, and efficacy, as well as prognostic factors and complications of preoperative embolization of bone metastases will be reviewed. New trends such as transradial arterial access and usage of liquid embolic agents will be discussed. Large tumor size, increased preprocedural tumor vascularity, longer embolization-to-surgery interval, and radical surgical procedures are associated with greater intraoperative blood loss and prolonged operative time. An accurate, noninvasive method to evaluate tumor vascularity prior to angiography is needed to identify patients who are most likely to benefit from preoperative embolization. Particular attention will be paid to skeletal metastases and spinal metastases as each has its own set of complexity.

Update on Preoperative Embolization of Bone Metastases.

Effectiveness of Preoperative Embolization in Patients with Spinal Metastases: A Systematic Review and Meta-Analysis.

Neurologic Complications of Preoperative Embolization of Spinal Metastasis: A Systemic Review of the Literature Identifying Distinct Mechanisms of Injury

Metastatic Renal Cell Carcinoma to the Spine: Outcomes and Morbidity: Single-Center Experience.

Purpose The purpose of the study was to assess the effectiveness and safety of preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression (MESCC). Methods A retrospective analysis of 138 MESCC patients who underwent decompressive surgery and spine stabilization was performed in a large teaching hospital. Among all enrolled patients, 46 patients were treated with preoperative embolization (the embolization group), whereas 92 patients did not (the control group). Patient’s baseline clinical characteristics, surgery-related characteristics, and postoperative neurological status, complications, and survival prognoses were collected and analyzed. Subgroup analysis was performed according to the degree of tumor vascularity between patients with and without preoperative embolization. Results Patients with severe hypervascularity experienced more mean blood loss in the control group than in the embolization group, and this difference was statistically significant (P=0.02). The number of transfused packed red cells (PRC) showed a similar trend (P=0.01). However, for patients with mild and moderate hypervascularity, both blood loss and the number of PRC transfusion were comparable across the two groups. Regarding decompressive techniques, the embolization group (64.29%, 9/14) had a higher proportion of circumferential decompression in comparison to the control group (30.00%, 9/30) among patients with severe hypervascularity (P=0.03), whereas the rates were similar among patients with mild (P=0.45) and moderate (P=0.54) hypervascularity. In addition, no subgroup analysis revealed any statistically significant differences in operation time, postoperative functional recovery, postoperative complications, or survival outcome. Multivariate analysis showed that higher tumor vascularity (OR[odds ratio]=3.69, 95% CI [confident interval]: 1.30-10.43, P=0.01) and smaller extent of embolization (OR=4.16, 95% CI: 1.10-15.74, P=0.04) were significantly associated with more blood loss. Conclusions Preoperative embolization is an effective and safe method in treating MESCC patients with severe hypervascular tumors in terms of intra-operative blood loss and surgical removal of metastatic tumors. Preoperative tumor vascularity and extent of embolization are independent risk factors for blood loss during surgery. This study implies that MESCC patients with severe hypervascular tumors should be advised to undergo preoperative embolization.

/pdf/preoperative-embolization-in-the-treatment-of-patients-with-1nwy5bnv.pdf

Preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression: A retrospective analysis

The objective of this paper is analyzing the effects of preoperative embolization on intraoperative blood loss in spinal surgery for renal cell carcinoma (RCC) metastasis and identifying factors contributing to an increased blood loss in the surgical procedure. A retrospective analysis was performed in patients who were treated in for spinal metastasis from RCC between 2011 and 2016. Factors analyzed were reduction of tumor blush, timing of embolization, selective vs. superselective approach, surgical factors, and tumor volume and localization. Parameters were statistically correlated with intraoperative blood loss (hemoglobin (Hg) decrease, blood loss in milliliters, number of transfused blood bags). Twenty-five patients with 34 surgical interventions were included. Seventeen cases were treated superselectively and 11 treated selectively. Mean perioperative blood loss was 2248 ± 1833 ml. Higher blood loss was detected for vertebra replacement compared to percutaneous procedures (Hg decrease 4.22 vs. 2.62, p   100 ccm) for Hg loss (3.29/3.64/4.24 mg/dl, NS), blood loss in milliliters (1291/2620/4971 ml, p   90%/90–75%/75–50%) for Hg loss, blood loss, or number of transfusions. Endovascular embolization for RCC metastasis of the spine is a safe procedure; however, in this cohort, patients undergoing embolization did not show a reduced blood loss in comparison to the non-embolized cohort. Additional factors contributing to an increased blood loss were tumor size and mode of surgery.

Surgical treatment of spinal metastases from renal cell carcinoma-effects of preoperative embolization on intraoperative blood loss

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Surgical treatment of spinal metastases from renal cell carcinoma-effects of preoperative embolization on intraoperative blood loss