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OBJECTIVES:Hyperthermic isolated limb perfusion (HILP) regional chemotherapy is an effective treatment option for patients with multifocal melanoma confined to a single extremity. However, due to the technical and physiologic demand of implementing HILP, an alternative technique, hyperthermic isolated limb infusion (HILI), has been developed. Traditionally, this endovascular technique has required a tourniquet to isolate the affected extremity, which has significant limitations to treatment of high inguinal disease. We propose a less invasive endovascular technique for HILI that may provide more comprehensive chemotherapy treatment and avoid associated wound complications of arterial exposures.
METHODS: The contralateral common femoral artery and vein are accessed under ultrasound guidance. Proglide closure devices are used to “pre-close” the arteriotomy. “Up and over” access to the ipsilateral limb is established in both the common femoral artery and vein on the affected side. Using an 8 or 9 French platform, specialized occlusion catheters (Stryker 9Fr Merci or 8Fr Flowgate catheters) are positioned above the level of the inguinal ligament in the external iliac vessels. Following systemic heparinization, the occlusion catheters are inflated and tested to ensure sufficient isolation of the limb circulation. The catheters are then connected through an infusion circuit using a Belmont® Rapid Infuser and CellsaverTM autotransfusion system for infusion of Melphalan. Limb infusion rates over 30 minutes are recorded to determine the dose of Melphalan delivered.
RESULTS: A total of three patients received HILI via an exclusively percutaneous approach within the last year. All three patients were treated for lower extremity multifocal melanoma below the inguinal ligament. There were no observed intraoperative complications. Infusion flow rates averaged 350 ml/min for 30 minutes with 50-80 milligrams of Melphalan in the circuit. Total blood loss ranged from 20 to 250 milliliters. There were no associated limb complications (arterial or venous) within 30 days of surgery. All patients ambulated on POD #1 with a length of stay of 2±0.5 days, and are alive with complete tumor responses to date (average follow-up 6 months).
CONCLUSIONS:We report our initial experience with a novel technique in three patients receiving exclusively percutaneous hyperthermic isolated limb infusions with no observed arterial or venous complications. The described approach to HILI is less invasive and may provide more thorough treatment of patients with multifocal melanoma of the lower extremity.