Elsevier

World Neurosurgery

Volume 111, March 2018, Pages e799-e805
World Neurosurgery

Original Article
Usefulness and Stability of Intraoperative Digital Subtraction Angiography Using the Transradial Route in Arteriovenous Malformation Surgery

https://doi.org/10.1016/j.wneu.2017.12.164Get rights and content

Highlights

  • Intraoperative angiography is a useful tool for completeness of AVM surgery.

  • We report the use of iDSA with the transradial approach and examine its usefulness and safety.

  • This approach demonstrated easy access, no extra requirements, and usefulness in prone or lateral surgical position.

Background

Digital subtraction angiography is the gold standard to confirm complete removal of an arteriovenous malformation (AVM) nidus. However, the transfemoral approach requires specialized instrumentation and is cumbersome and difficult to perform with the patient in the prone or decubitus position. We report the use of intraoperative digital subtraction angiography (iDSA) with the transradial approach and examine its usefulness and safety.

Materials and Methods

We retrospectively reviewed clinical features, radiologic images, surgical findings, and iDSA findings of patients with AVM who underwent surgery for nidus removal. Transradial iDSA was performed within 30 minutes for patients who required angiographic confirmation after AVM resection. This procedure was simple with the radial arterial line for blood pressure monitoring used as digital subtraction angiography catheter access route.

Results

Transradial iDSA was performed in 23 patients. Twelve patients were not in the general supine position during neurosurgery; 7 patients were operated on in prone position, and 5 patients were operated on in the park bench position. Remnant nidus was identified by iDSA in 2 patients, and additional measures were required.

Conclusions

Intraoperative cerebral angiography during surgery for cerebral AVM could be performed safely via the transradial approach. This approach showed several merits in terms of easy access; no extra requirements, such as preoperative sheath implantation, anticoagulation during the surgery, or a radiolucent table; and usefulness in any surgical position. Further studies using this approach and comparison with the transfemoral approach are necessary.

Introduction

Although endovascular embolization and stereotactic radiosurgery are now frequently used to treat cerebral arteriovenous malformations (AVMs),1, 2 microsurgery is still the mainstay of AVM treatment.3 Owing to its complex vascular anatomy and hemodynamics, intraoperative confirmation of complete extirpation of an AVM from the normal brain vasculature and detection of any complicated features are crucial in AVM surgery.4 Despite the development of imaging techniques such as contrast-enhanced ultrasonography, indocyanine green angiography (ICGA), and fluorescent angiography, catheter angiography is still the gold standard modality for this purpose.5, 6, 7 Intraoperative angiography is typically performed via the transfemoral approach. However, this approach has some drawbacks, as it requires additional equipment, such as a radiolucent surgical table and head rest system, and is associated with some procedural difficulties induced by unfamiliar surgical positioning.5, 8 Because we routinely perform transradial cerebral angiography (TRCA), we are very familiar with this procedure and aware of its feasibility, merits, and safety.9 To overcome the drawbacks of the transfemoral approach, we examined the transradial approach for intraoperative angiography in cerebral AVM surgery. The present study describes the technique and features of intraoperative transradial cerebral angiography (iTRCA) during AVM surgery.

Section snippets

Materials and Methods

We retrospectively analyzed data regarding cerebral AVM treatment in our hospital from 2009 to 2016. During this period, 189 multimodality treatment procedures were performed in 150 patients with cerebral AVMs. Forty-five cases required surgical intervention. Of these surgical cases, iTRCA was performed in 23 cases. Computed tomography (CT) of the brain performed immediately postoperatively and routine postoperative contrast-enhanced magnetic resonance imaging of the brain were reviewed for

Results

The demographics of patients and outcomes are summarized in Table 1. Surgery was performed to treat 23 cases of intracerebral AVM, and corresponding iTRCA was performed. The success rate of iTRCA was 100%. Although the exact duration of iTRCA was not measured or recorded, it took approximately 30 minutes from draping to the end of the procedure. All 23 removed AVM lesions were evaluated by iTRCA, and the findings were compared with intraoperative surgical microscopic fields. Complete resection

Discussion

Incomplete resection can expose patients to the subsequent risk of hemorrhage and its potentially devastating consequences.3, 12 Owing to the complexity of cerebral AVM surgery, the incidence of a residual nidus is 8.9%–15% even for expert neurosurgeons.13, 14 Therefore, intraoperative detection of the residual nidus is very important, and iDSA is useful for this purpose.7 However, there are several technical challenges, including the need for skilled neuroradiology staff or a dual-trained

Conclusions

Intraoperative cerebral angiography during surgery to treat cerebral AVM can be performed safely via the transradial approach. This approach demonstrated several merits in terms of easy access; no extra requirements, such as preoperative sheath implantation, anticoagulation during surgery, or a radiolucent table; and usefulness in any surgical position. Further studies using this approach and comparison with the transfemoral approach are necessary.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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