Indications
1.Medium to late stage central type and peripheral type lung cancer as the main target.
2.Those who are contraindicated to surgery or refuse surgery although they can be surgically removed
3.Those who need local chemotherapy to improve the efficacy before surgery
4.Patients with small cell lung cancer who do not receive systemic chemotherapy
5.Patients who do not receive systemic chemotherapy although they have metastases inside and outside the chest.
Contraindications
1, cachexia or heart, lung, liver and kidney failure.
2, high fever, severe infection or significantly low white blood cell count (less than 3×109/l).
3.Severe bleeding tendency and iodine allergy are contraindications to angiography.
Preoperative preparation
1. definite diagnosis: routine chest X-ray, enhanced CT to clarify tumor size, location, number, tumor blood supply arteries; head, abdomen, pelvis CT or mr to perform pet-CT if necessary to clarify whether there is metastasis; sputum, tracheoscopy or thoracic or percutaneous puncture to obtain histological diagnosis; laboratory tests: routine blood, clotting time, liver and kidney function, neuron-specific enolase (nse, lung cancer specific index)
2. Equipment and devices preparation: must have a digital subtraction angiography machine (dsa) in good operation; catheters: cobra and other conventional catheters, microcatheters; other auxiliary equipment.
Patient preparation
1. interview signature.
2.Iodine allergy test.
3.Fast four hours before the procedure.
Technical operation
Arterial access
1.Regularly choose the femoral artery puncture access, take the femoral artery 2cm below the inguinal ligament to perform seldinger technique puncture and introduce the catheter sheath.
2, the elderly or iliac artery tortuous obvious catheter is not easy to go up, can use 25cm long catheter sheath.
3, the brachial artery can be punctured if the iliac artery is occluded or if the catheter cannot be introduced with severe tortuosity.
Finding the blood supply artery
1.Insert the catheter through the catheter sheath with a guidewire, send the catheter tip to the level of the descending aorta under fluoroscopy, and inject dexamethasone 10mg and antiemetic through the catheter or IV.
2.Let the catheter tip be pushed up and down at the level of 4~6 vertebrae along the anterior and posterior walls of the aorta.
3.After confirming that it is the target vessel, slightly rotate and upward feed the catheter, fix the catheter tip, inject 30~45% non-ionic contrast agent at the rate of 1~2ml, and perform dsa imaging. Observe the travel and distribution of the blood supplying bronchial arteries and the staining of tumor and metastatic lymph nodes, the presence or absence of collateral traffic, and especially the presence or absence of cremasteric artery branches.
If no blood supplying bronchial artery can be found, it may be: vagus artery supply; abnormal origin of bronchial artery or multiple bronchial arteries and each branch is very small.
The response is to replace the catheter; expand the search to include the subclavian artery and the thyroglossal trunk, as well as the renal artery and phrenic artery. After finding one blood supplying artery and imaging, if only part of the tumor stains, or the enhanced ct staining is obvious but the dsa imaging staining is light, the most likely is that the tumor has more than one artery supplying blood. After perfusing or embolizing this vessel, the search for other blood supplying arteries should be continued.
bai regimen
1.Differences in the mode of arteriovenous drug delivery lead to different pharmacokinetics, which affect the action of chemotherapeutic drugs in the lung.
2. What drugs to use for lung cancer bai, how to dose them, and how large a dose is still a problem to be studied, and at present, we have to refer to the experience of clinical departments in using drugs. Their study showed that the efficacy of platinum-based three-drug regimen is close to that of two-drug regimen.
3, we used microdialysis (microdialysis) technology to find that the intrapulmonary clearance phase of carboplatin bai is significantly longer and drug clearance is slower than that of intravenous administration of equal doses.
4. Therefore, we advocate a two-drug regimen based on platinum-based drugs.
The recommended regimens are as follows
Non-small cell lung cancer carboplatin 200mg/m2 or cisplatin 60mg/m2 + adriamycin 50mg/m2
Small cell lung cancer carboplatin 200mg/m2 or cisplatin 60mg/m2+ghostoside 200mg/m2
Perfusion method
1.Drugs were dissolved in 50~100ml of saline (sugar water for cbp) and perfused one by one for 15~30min, with intermittent fluoroscopy to ensure the catheter head was in position.
2.When there are multiple arteries supplying blood, it can be proportionally divided into several injections, and the scope should include the involved lymph nodes.
3.When the intercostal arteries of the bronchial arteries are common, avoid the intercostal arteries as much as possible or embolize them protectively.
4.When there is a crestal trophic artery, it must be avoided.
5.The use of microcatheters and arterial syringe pumps is advocated for perfusion.
Bronchial artery embolization (bae)
Tumor blood supply is rich, the blood supplying artery is thick or there is bronchial artery-pulmonary artery or pulmonary vein fistula and there is no crista nutritiva artery and head and neck traffic branch or can be super-selected to avoid. Gelatin sponge granules, super liquid iodine oil (lipodol)
Gelatin sponge embolization
1.Advantages: good efficacy and low risk.
2.Disadvantage: easy to cause permanent occlusion of bronchial artery.
3. Under fluoroscopy, the mixture of gelatin sponge particles and contrast agent below 1mm3 is slowly pushed through the catheter and can be stopped when the flow rate slows down significantly.
4., Avoid regurgitation and excessive embolization of the trunk causing permanent occlusion.
Iodine oil embolization
1. Advantages: better efficacy than gelatin sponge, and can be used as a carrier for chemotherapy drugs.
2. Disadvantages: risky, must be superselected, and cannot be used for those with bronchial artery and pulmonary vein traffic.
Prevention of cristae injury
Causes: Anastomosis of bronchial artery and cremaster artery occurs mostly when the right bronchial artery and intercostal artery are co-intermediated. Highly concentrated contrast agents, especially hypertonic ionic contrast agents, drugs directly damage the crural medulla, or tiny particles obstruct the root medullary artery causing crural medullary ischemia.
Manifestations of crestal medullary injury Symptoms of transverse crestal medullary injury begin to appear a few hours after surgery, with reduced or absent sensory and motor functions below the plane of injury: such as numbness of the extremities, urinary and bowel disorders, and lack of movement of both lower extremities.
Prevention of crestal medullary injury
1, prohibit the use of ionic contrast agents, non-ionic contrast agents also need to be diluted, injection pressure should not be too high.
2, super-selective cannulation to prevent regurgitation, and advocate microcatheters.
3. Bronchial arteriography: if “hairpin sign” is found, it must be super-selected for treatment.
4.Bronchial arteriogram cta is feasible if available, if the crestal medulla is obviously strengthened, in principle, do not treat.
Efficacy evaluation
Clinical symptoms quality of life solid tumors: cr, pr, nc, pd metastasis survival
Evaluation methods
Plain film, ct─solid tumor changes pet-ct─metastasis angiography─tumor vascular changes chemistry─tumor indicators clinical─quality of life evaluation time, single perfusion chemotherapy before each treatment, 2~3 weeks embolization chemotherapy, once a month.