Limb ischaemia is a clinically relevant complication of venoarterial extracorporeal membrane oxygenation (VA ECMO) with femoral artery cannulation. No selective distal perfusion or other advanced techniques were used in the past to maintain adequate distal limb perfusion. A more recent trend is the shift from the reactive or emergency management to the pro-active or prophylactic placement of a distal perfusion cannula to avoid or reduce limb ischaemia-related complications. Multiple alternative cannulation techniques to the distal perfusion cannula have been developed to maintain distal limb perfusion, including end-to-side grafting, external or endovascular femoro-femoral bypass, retrograde limb perfusion (e.g., via the posterior tibial, dorsalis pedis or anterior tibial artery), and, more recently, use of a bidirectional cannula. Venous congestion has also been recognized as a potential contributing factor to limb ischaemia development and specific techniques have been described with facilitated venous drainage or bilateral cannulation being the most recent, to reduce or avoid venous stasis as a contributor to impaired limb perfusion. Advances in monitoring techniques, such as near-infrared spectroscopy and duplex ultrasound analysis, have been applied to improve decision-making regarding both the monitoring and management of limb ischaemia. This narrative review describes the evolution of techniques used for distal limb perfusion during peripheral VA ECMO.

• Klíčová slova
• distal perfusion, extracorporeal membrane oxygenation, limb perfusion, venoarterial,
• MeSH
• arteria femoralis * MeSH
• dospělí MeSH
• ischemie prevence a kontrola   etiologie   MeSH
• katetrizace metody   MeSH
• končetiny krevní zásobení   MeSH
• lidé MeSH
• mimotělní membránová oxygenace * metody   MeSH
• perfuze metody   MeSH
• periferní katetrizace metody   škodlivé účinky   MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

BACKGROUND: Hyperthermic isolated limb perfusion uses therapeutic effect of hyperthermia in the bounded compartment of the limb together with increased concentration of chemotherapy effect than what would be achieved in systemic application. Gold standard was melphalan (Alkeran) in combination with tasonermin (Beromun, tumor necrosis factor alpha). The efficacy of this combination has been demonstrated in limb soft tissue sarcomas and in patients with limb isolated bulky disease of malignant melanoma. CASE: We describe a case of a 65-year-old female patient with undifferentiated spindle-cell sarcoma treated by a multidisciplinary team at the 2nd Surgical Clinic of Cardiovascular Surgery and Clinic of Oncology General University Hospital in Prague and at the Department of Orthopaedics Na Bulovce Hospital with the aim of preserving the limb despite the advanced disease. The patient underwent hyperthermic isolated limb perfusion with tasonermin and melphalan with partial response on magnetic resonance imaging. Subsequent wide resection was done with complete pathological remission according to histological examination maintaining a fully functional limb. The patient is followed without signs of recurrence. CONCLUSION: Hyperthermic isolated limb perfusion with tasonermin and melphalan is an important part of a multimodal approach in the treatment of extremity sarcomas with a high percentage of responses that increase the percentage of limbs retaining resections. Multidisciplinary team should consider this option in patients with localized limb sarcomas and should be performed in specialized centers with experience in this procedure. This work was supported by project Progres Q28-LF1. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.

• Klíčová slova
• complete remission, hypertermic isolated perfusion, lower limb, soft tissue sarcoma, tasonermin,
• MeSH
• chemoterapie nádorů pomocí regionální perfúze metody   MeSH
• dolní končetina MeSH
• indukovaná hypertermie metody   MeSH
• lidé MeSH
• magnetická rezonanční tomografie MeSH
• melfalan aplikace a dávkování   MeSH
• neoadjuvantní terapie MeSH
• sarkom diagnostické zobrazování   patologie   terapie   MeSH
• senioři MeSH
• TNF-alfa aplikace a dávkování   MeSH
• Check Tag
• lidé MeSH
• senioři MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH
• Názvy látek
• melfalan MeSH
• TNF-alfa MeSH

BACKGROUND: Isolated limb perfusion (ILP) is a well-established surgical procedure for the administration of high dose chemotherapy to a limb for the treatment of advanced extremity malignancy. Although the technique of ILP was first described over 60 years ago, ILP is utilised in relatively few specialist centres, co-located with tertiary or quaternary cancer centres. The combination of high dose cytotoxic chemotherapy and the cytokine tumour necrosis factor alpha (TNFα), mandates leakage monitoring to prevent potentially serious systemic toxicity. Since the procedure is performed at relatively few specialist centres, an ILP working group was formed with the aim of producing technical consensus guidelines for the procedure to streamline practice and to provide guidance for new centres commencing the technique. METHODS: Between October 2021 and October 2023 a series of face to face online and hybrid meetings were held in which a modified Delphi process was used to develop a unified consensus document. After each meeting the document was modified and recirculated and then rediscussed at subsequent meeting until a greater than 90% consensus was achieved in all recommendations. RESULTS: The completed consensus document comprised 23 topics in which greater than 90% consensus was achieved, with 83% of recommendations having 100% consensus across all members of the working group. The consensus recommendations covered all areas of the surgical procedure including pre-operative assessment, drug dosing and administration, perfusion parameters, hyperthermia, leakage monitoring and theatre logistics, practical surgical strategies and also post-operative care, response evaluation and staff training. CONCLUSION: We present the first joint expert-based consensus statement with respect to the technical aspects of ILP that can serve as a reference point for both existing and new centres in providing ILP.

• MeSH
• chemoterapie nádorů pomocí regionální perfúze * metody   MeSH
• delfská metoda MeSH
• končetiny * krevní zásobení   MeSH
• konsensus MeSH
• lidé MeSH
• nádory MeSH
• TNF-alfa MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH
• směrnice pro lékařskou praxi MeSH
• Názvy látek
• TNF-alfa MeSH

Large unresectable STS presents a therapeutic challenge. Several options are being explored to avoid amputation without compromising the oncological outcome. Neoadjuvant chemotherapy delivers inconsistent and rather unsatisfactory results, preoperative radiotherapy compromises healing, hence it can impede adjuvant systemic treatment. We present a case report of neoadjuvant use of isolated limb perfusion with TNF-alfa and Alkeran (Melphalan) in a patient with initially unresectable large myxoid liposarcoma of the thigh. We achieved 55% reduction in size of the tumor that allowed for wide resection with a safe margin. Pathology confirmed 99% tumor necrosis. The patient has a full function of his extremity and is disease-free at one year follow-up. ILP should be considered as a treatment option which, in selected cases, can contribute to limb sparing surgery. Key words: sarcoma, soft tissue, regional perfusion, chemotherapy, surgery, orthopedic, limb salvage.

• MeSH
• chemoterapie nádorů pomocí regionální perfúze MeSH
• dospělí MeSH
• končetiny MeSH
• lidé MeSH
• myxoidní liposarkom * diagnostické zobrazování   farmakoterapie   chirurgie   MeSH
• neoadjuvantní terapie * MeSH
• perfuze MeSH
• stehno MeSH
• záchrana končetiny MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH

BACKGROUND: Hyperthermic isolated limb perfusion is used to treat irresectable extremity malignancies. It is based on the following principle - the perfusion of the extremity is isolated from systemic circulation and connected to an extra-corporal circuit via which a very high concentration of a chemotherapeutic agent is administered into the blood compartment of the extremity. In some cases, treatment efficiency can be improved using tasonermin (a TNF-α agent). By itself, tasonermin can cause severe health complications in patients if leakage into systemic circulation results in a level that exceeds the maximally tolerated dose. Therefore, it is important to monitor for leakage during the whole operation. METHOD: Leakage monitoring was performed by a nuclear medicine method based on the measurement of activity of a gamma-emitting radiotracer detected by a scintillation probe located over the heart. An amount of radiotracer that resulted in a basal level of measured signal was first administered into the systemic circuit followed by the administration of a second, one order of magnitude higher amount of radiotracer into the perfusion circuit. Leakage, when it occurred, increased the count rate detected over the heart, and the mathematical relation between leakage level and count rate increase was derived. RESULTS: In our department, the method was tested and optimized during isolated limb perfusion without using a TNF-α agent. Then, accreditation for the use of TNF-α was granted. Since then, the method has been used to monitor leakage in all cases of isolated limb perfusion with TNF-α. All isolated limb perfusion operations with TNF-α passed without complications. The radiation burden was almost negligible for both the patient and medical staff. CONCLUSION: The method described in this report represents a reliable method for perfusion leakage monitoring when using TNF-α in our department.Key words: perfusion - isolated limb - TNF-α - leakage - monitoring - nuclear medicine - radiopharmaceuticalsThe authors declare they have no potential confl icts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 16. 6. 2016Accepted: 21. 6. 2016.

• MeSH
• chemoterapie nádorů pomocí regionální perfúze * MeSH
• extravazace diagnostických a terapeutických materiálů diagnostické zobrazování   metabolismus   MeSH
• kombinovaná terapie MeSH
• končetiny diagnostické zobrazování   patologie   MeSH
• lidé MeSH
• nádory diagnostické zobrazování   patologie   terapie   MeSH
• prognóza MeSH
• protinádorové látky terapeutické užití   MeSH
• radiofarmaka metabolismus   MeSH
• radioisotopová scintigrafie MeSH
• terapeutická hypotermie * MeSH
• TNF-alfa aplikace a dávkování   metabolismus   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• Názvy látek
• protinádorové látky MeSH
• radiofarmaka MeSH
• TNF-alfa MeSH

Perfusion scintigraphy with technetium-99-methoxy-isobutyl-isonitrile ((99m)Tc-MIBI) is often used for assessing myocardial function but the number of studies concerning lower limb perfusion is limited. The aim of our study was to assess whether (99m)Tc-MIBI was an eligible method for evaluation of the effect of cell therapy on critical limb ischemia (CLI) in diabetic patients. (99m)Tc-MIBI of calf muscles was performed before and 3 months after autologous cell therapy (ACT) in 24 diabetic patients with CLI. Scintigraphic parameters such as rest count and exercising count after a stress test were defined. These parameters and their ratios were compared between treated and untreated (control) limbs and with changes in transcutaneous oxygen pressure (TcPO(2)) that served as a reference method. The effect of ACT was confirmed by a significant increase in TcPO(2) values (p<0.001) at 3 months after ACT. We did not observe any significant changes of scintigraphic parameters both at rest and after stress 3 months after ACT, there were no differences between treated and control limbs and no association with TcPO(2) changes. Results of our study showed no significant contribution of (99m)Tc-MIBI of calf muscles to the assessment of ACT in diabetic patients with CLI over a 3-month follow-up period.

• MeSH
• autologní transplantace trendy   MeSH
• bérec diagnostické zobrazování   MeSH
• buněčná a tkáňová terapie trendy   MeSH
• diabetes mellitus 2. typu diagnostické zobrazování   terapie   MeSH
• diabetická noha diagnostické zobrazování   terapie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• perfuzní zobrazování metody   MeSH
• senioři MeSH
• technecium 99mTc sestamibi MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• Názvy látek
• technecium 99mTc sestamibi MeSH

The present study aimed to evaluate the characteristic influence of physical therapeutic procedures of vacuum-compression therapy (VCT) on microvascular perfusion (MiP) and macrovascular perfusion (MaP) of the lower limb in diabetic patients. A sample of nine patients with a medical history of type 2 diabetes was used for the purpose of this study. Most of the subjects' medical conditions included venous and neurological complications of the lower limb, whereas the rest of the subjects entered the treatment due to injury recovery or their phlebological disease. The PeriFlux System 5000 (Perimed, Sweden) diagnostic device was used to measure MiP. The MaP was evaluated based on the perfusion index (PI) using the Extremiter monitoring device (Embitron, Czech Republic) designed to perform VCT procedures. The study found that MiP and MaP increase as an effect of VCT procedures and at the same time PI clearly reflects the effect of the applied vacuum and compression phases, verifying the method's vital influence on peripheral perfusion disorders.

• Klíčová slova
• diabetes, macrovascular perfusion, microvascular perfusion, perfusion index, vacuum-compression therapy,
• MeSH
• diabetes mellitus 2. typu komplikace   diagnóza   patofyziologie   MeSH
• diabetická retinopatie MeSH
• dolní končetina patofyziologie   MeSH
• lidé MeSH
• perfuze metody   MeSH
• vakuum MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

• MeSH
• alkylační látky aplikace a dávkování   MeSH
• antimetabolity aplikace a dávkování   MeSH
• chemoterapie nádorů pomocí regionální perfúze * MeSH
• končetiny * MeSH
• lidé MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• Názvy látek
• alkylační látky MeSH
• antimetabolity MeSH

Hyperthermic isolated limb perfusion (HILP) is a standardized method of treatment in selected patients with in-transient locoregional recurrence/methastasis of melanoma or, some other soft tissue tumors (incl. sarcoma etc.) Authors present history and current status of this treatment modality in General University Hospital in Prague. During one year period (7/2009-6/2010) 10 patients were indicated for this procedure. We performed 13 procedures (3x redo), 11 in lower extremity and 2 in upper extremity. There was no serious complication in this cohort of patiens. Multidisciplinar approach is indicated in melanoma patients care.

• MeSH
• chemoterapie nádorů pomocí regionální perfúze * MeSH
• indukovaná hypertermie * MeSH
• končetiny * MeSH
• lidé MeSH
• melanom terapie   MeSH
• melfalan aplikace a dávkování   MeSH
• TNF-alfa aplikace a dávkování   MeSH
• Check Tag
• lidé MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH
• Publikační typ
• anglický abstrakt MeSH
• časopisecké články MeSH
• Názvy látek
• melfalan MeSH
• TNF-alfa MeSH

BACKGROUND: Lower limb defects may be present due to various causes including infections, vascular diseases, tumor resections, and crush or avulsion injuries. Management of lower leg defects is a complex problem, especially when they are large with deep soft tissue loss. These wounds are difficult to be covered with local skin flaps, distant skin flaps or even conventional free flaps because of the compromised recipient vessels. In such cases, the vascular pedicle of the free flap could be anastomosed to the recipient vessels of the contralateral healthy leg temporarily and then divided after adequate neo-vascularization of the flap from the wound bed. The ideal time to divide such pedicles should be investigated and accurately assessed to have the maximum success rate possible for these challenging conditions and procedures. METHODS: Sixteen patients who did not have a suitable adjacent recipient vessel for free flap reconstruction had been operated with cross leg free latissimus dorsi flap between February 2017 and June 2021. The mean soft tissue defect dimension was 12 × 11 cm (the smallest 6 × 7 cm; the largest 20 × 14 cm). Gustilo type 3B tibial fractures were present in 12 patients, while no fractures were present in the other 4 patients. Preoperatively, arterial angiography was performed on all patients. After the fourth week post-operatively, non-crushing clamp was applied around the pedicle for 15 minutes. The clamping time was increased by 15 minutes on each consequent day (average 14 days). On the last 2 days, the pedicle was clamped for 2 hours, and bleeding was assessed by a needle prick test. RESULTS: Clamping time was assessed in each case to reach a scientific calculation of the adequate vascular perfusion time needed for full flap nourishment. All flaps survived completely except two cases of distal flaps necrosis. CONCLUSION: Cross-leg free latissimus dorsi can provide a solution for large soft-tissue defects in lower extremities especially with absence of any suitable recipient vessels or when the use of vein grafts would not be feasible. However, ideal time before dividing the cross vascular pedicle should be identified to have the maximum success rate possible.

• Klíčová slova
• Perfusion, cross-leg, free flap, vascular,
• MeSH
• bérec MeSH
• dolní končetina MeSH
• lidé MeSH
• myokutánní lalok * MeSH
• nemoci cév * MeSH
• perfuze MeSH
• povrchové zádové svaly * MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH