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Isolated limb perfusion (ILP) for malignant melanoma

Implementation

Vascular access

ILP can be carried out via the following veins:

  • Upper extremity:
    • Axillary vein
    • Brachial vein
  • Lower extremity:
    • External iliac vein
    • Femoral vein
    • Popliteal vein 

Iliac access is used often for lower limb perfusions.

  • A diagonal incision is made across the iliacal fossa.
  • The fascia and muscles are cut.
  • Dissection down to the external iliac veins. 
  • Vascular control is secured proximally and distally with vessel loop.
  • The side branches are ligated.
  • Anticoagulation with heparin is administered.
  • Venous and arterial cannulas are inserted. 
  • A tourniquet is placed proximally on the thigh. 
  • Temperature probes are inserted in the extremity both in subcutaneous tissue and in the muscle distally and proximally.  

Perfusion

  • The cannulas are connected to the heart/lung machine. 
  • Perfusion is maintained at 400–500 ml/min for lower extremity and 150–300 ml/min for upper extremity. 
  • For large melanoma metastases TNF is added to the perfusion and circulated for 30 minutes.
  • The perfusion is heated to 38.5–39.5°C.
  • Melfalan is added.
  • The duration of the perfusion with melfalan is 60 minutes. Total duration of the entire perfusion when TNF is added to melfalan is 90 minutes.

Monitoring of leakage

  • Potential leakage is measured with radioactive-labeled albumin, which is injected into the perfusate.
  • A gamma detector is placed over the heart. 
  • Radioactivity in perpheral plasma is monitored continually with specialized software. 
  • For leakage > 10 %, it must be decided whether the perfusion should be interrupted due to risk of systemic toxicity.

Completion of ILP

  • The drug perfusion is stopped and the extremity is perfused with 3-5 L Macrodex. 
  • The pump is turned off and the tourniquet and cannula removed. 
  • The veins are sutured and the circulation is reestablished in the extremity.
  • The incision is closed.

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