Isolated limb infusion with cytotoxic agents: A simplified approach for venous access

Abstract

BACKGROUND: Isolated limb infusion (ILI) of cytotoxic agents is a regional therapy for cutaneous malignancies in a single extremity. Conventional ILI technique requires retrograde catheterization of the contralateral femoral vein. A novel modified ILI technique uses an ipsilateral popliteal venous approach. The purpose of this study was to compare the performance of ILI using the 2 different approaches. METHODS: Data from patients who underwent lower-extremity ILI at the authors' institution between October 2005 and June 2008 were retrospectively reviewed. The authors compared the 2 ILI approaches with regard to overall procedure time, fluoroscopy time, and the number of callbacks to the operating room (OR) for flow-related issues. The Student t test and Fisher exact test were used. Adverse events, including deep venous thrombosis (DVT) in the treated limb, were recorded. RESULTS: Between October 2005 and June 2008, 67 lower-extremity ILI procedures (15 using a contralateral venous access approach and 52 using an ipsilateral venous access approach) were performed in 62 patients (28 men and 34 women aged 31-82 years). The mean fluoroscopy times for the contralateral and ipsilateral groups were 17.9 and 8.3 minutes, respectively (P ¼ .0019). No significant difference in the overall procedure time and number of callbacks to the OR for flow-related issues between the 2 groups was identified. CONCLUSIONS: The ipsilateral popliteal venous approach is a simplified and safe ILI technique with significantly lower overall fluoroscopy procedure times required for catheter placement and no difference in catheter-related adverse events, when compared with the conventional contralateral approach. Cancer 2010;116:459-64.

A multi‐institution experience comparing the clinical and physiologic differences between upper extremity and lower extremity melphalan‐based isolated limb infusion

“…Consequently, to maximize ILI flow rates, 1 center has described placing a shorter venous catheter below the tourniquet on the ipsilateral side to improve blood flow and, thus, the total volume of blood circulated through the ILI circuit. 7 Because ILI procedures of the UE are associated with lower flow rates, we sought to examine whether there were differences in response or toxicity between UE ILI and LE ILI. Furthermore, most studies combine the results from both UE and LE procedures without separate examination, although the patients are dosed differently for melphalan.…”

“…Toxicity after all completed procedures (n = 47) was evaluated using the Wieberdink toxicity scale. 7 Grade 3 toxicities included considerable edema and blistering, whereas grade 4 toxicities were compartment syndromes. Treatment response to ILI performed for melanoma only (n = 36) was evaluated according to Response Evaluation Criteria in Solid Tumors (RECIST) 3 months after the procedure.…”

“…It is believed that maximizing the flow rate during ILI is critical for optimal drug exposure. 7 Despite the lower flow rates typically achieved with UE in contrast to LE ILI, drug distribution may be better achieved in smaller limb volumes as opposed to larger limbs. In the multicenter US study of 75 ILI procedures, patients who had an overall response to treatment (partial responses [PRs] þ CRs) had significantly smaller limb volume (6.45 AE 2.1 L) than patients who did not respond (8.01 AE 347 L; P ¼ .021).…”

Nursing Care of Patients Undergoing Isolated Limb Procedures for Recurrent Melanoma of the Extremity

“…Additionally, a recently published article described an ipsilateral approach for arterial and venous catheter placement before an isolated limb infusion of a lower extremity. 17 The lack of standardization for the placement of arterial and venous catheters before isolated limb infusion validates the need for nurses to understand the technical aspects of these procedures to provide appropriate nursing care. There are safety and quality-of-care concerns related to ongoing assessments and nursing attention to minimize the risk of catheter displacement.…”

Evaluation of the efficacy and toxicity of upper extremity isolated limb infusion chemotherapy for melanoma: An Australian multi-center study

“…(7) In an effort to overcome this, Vyas et al placed shorter venous catheters below the tourniquet on the ipsilateral side to improve blood flow. (22) In a similar fashion, at MIA/RPAH the venous catheter has occasionally been inserted antegrade via the wrist in UL-ILI cases, when venous access via the groin proved impossible, achieving satisfactory venous flow in these patients. With regard to the flow-rates, however, the ILI procedure was based on the "stop-flow" method of delivering cytotoxic drugs to tumors, as described by Aigner et al, (23)…”