Pre-operative endovascular occlusion for unresectable metastatic carcinoid tumor: technique and initial results

Purpose: Surgery is the only curative therapy for carcinoid patients; however, many are unresectable due to direct involvement of the superior mesenteric artery (SMA) branches. In these patients, we sought to improve surgical outcomes via arterial skeletonization of the SMA prior to surgical resection. Materials and methods: After left radial access, the SMA was catheterized, angiography was performed, and balloon occlusion was achieved in the tumor vessel. Following balloon occlusion of the affected artery, patients were assessed for symptoms of ischemia and angiographic evidence of distal perfusion via collaterals. If patients tolerated occlusion, an endovascular plug was deployed in the affected artery; if not, the procedure was terminated. The next day, all patients underwent exploratory laparotomy and surgical resection of tumor and bowel. Results: The procedure was performed 15 times on 14 patients. 13 out of 15 procedures went to embolization, while the other 2 proceeded to surgery without plug deployment. One of the embolized patients had serious post-surgical complications, while both non-embolized patients developed complications including short bowel syndrome and ischemic colitis. Length of stay between embolized and non-embolized patients was equal, but re-admittance within 30 days was 7.7% in the embolized group and 100% in the non-embolized group. Discussion: Our initial experience demonstrates feasibility and safety of deploying plugs within branches of the SMA prior to surgical resection and improved surgical outcomes. Palpation of the plug assisted in surgical resection. We have demonstrated that pre-operative endovascular occlusion is a safe, practical procedure, which aids surgical resection of mesenteric carcinoid disease.