Transfemoral Approach for Intraoperative Angiography in the Prone or Three-quarter Prone Position: A Revisited Protocol for Intracranial Arteriovenous Malformation and Fistula Surgery

Chi Wang, Szu Kai Hsu, Chih Ju Chang, Ming Hong Chen, Chih Ta Huang, Jing Shan Huang, I. Chang Su

Research output: Contribution to journalArticle

Abstract

Purpose: Among the different arterial accesses, the femoral access is the main approach for intraoperative angiography (IOA) performed in a prone position. Without a standardized protocol, however, the application of prone IOAs in intracranial arteriovenous malformation (AVM) or arteriovenous fistula (AVF) surgery remains limited by its procedural complexity. This study describes the detailed protocol for prone IOA through a transfemoral approach and highlights several refinements in preparing this procedure. Methods: This study retrospectively reviewed the intracranial or high cervical AVM/AVF surgical cases in which both resection and IOA were performed in the prone or three-quarter prone position. Extended femoral sheath approaches and radiolucent head clamps were used in all cases. An aneurysm clip, serving as a localization landmark in IOA, was routinely placed within the surgical field. The IOA imaging, clinical impact of IOA, and complications related to the procedure were recorded. Results: A total of six AVM and three AVF cases, operated on in the prone (n = 7) or three-quarter prone (n = 2) positions, were included. Multiple vessel injections were required in 66.7% of cases, and IOA was successfully performed in every intended vessel. All IOA images were adequate for interpretation, except for two cases in which the non-radiolucent component of the head clamp obscured the region of interest in the lateral views. Incomplete occlusion was identified in two patients, and the aneurysm clip provided precise guidance in localizing the residual nidus. Final IOA confirmed complete lesion removal in all cases, and there were no IOA-related complications. Conclusion: Three key steps in setting-up a prone IOA procedure for intracranial AVM/AVF surgery are proposed: (1) utilize an extended femoral sheath approach, (2) establish a localization landmark with an aneurysm clip and (3) avoid possible image interference from the non-radiolucent component of the head clamp.

Original languageEnglish
JournalClinical Neuroradiology
DOIs
Publication statusPublished - 2019
Externally publishedYes

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Intracranial Arteriovenous Malformations
Prone Position
Arteriovenous Fistula
Angiography
Thigh
Surgical Instruments
Aneurysm
Arteriovenous Malformations
Head
Intraoperative Complications

Keywords

  • Arteriovenous fistula
  • Arteriovenous malformation
  • Hybrid operating room
  • Intraoperative localization
  • Non-supine position

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Clinical Neurology

Cite this

@article{eb80536a96134a7e9931b9ae151efde3,
title = "Transfemoral Approach for Intraoperative Angiography in the Prone or Three-quarter Prone Position: A Revisited Protocol for Intracranial Arteriovenous Malformation and Fistula Surgery",
abstract = "Purpose: Among the different arterial accesses, the femoral access is the main approach for intraoperative angiography (IOA) performed in a prone position. Without a standardized protocol, however, the application of prone IOAs in intracranial arteriovenous malformation (AVM) or arteriovenous fistula (AVF) surgery remains limited by its procedural complexity. This study describes the detailed protocol for prone IOA through a transfemoral approach and highlights several refinements in preparing this procedure. Methods: This study retrospectively reviewed the intracranial or high cervical AVM/AVF surgical cases in which both resection and IOA were performed in the prone or three-quarter prone position. Extended femoral sheath approaches and radiolucent head clamps were used in all cases. An aneurysm clip, serving as a localization landmark in IOA, was routinely placed within the surgical field. The IOA imaging, clinical impact of IOA, and complications related to the procedure were recorded. Results: A total of six AVM and three AVF cases, operated on in the prone (n = 7) or three-quarter prone (n = 2) positions, were included. Multiple vessel injections were required in 66.7{\%} of cases, and IOA was successfully performed in every intended vessel. All IOA images were adequate for interpretation, except for two cases in which the non-radiolucent component of the head clamp obscured the region of interest in the lateral views. Incomplete occlusion was identified in two patients, and the aneurysm clip provided precise guidance in localizing the residual nidus. Final IOA confirmed complete lesion removal in all cases, and there were no IOA-related complications. Conclusion: Three key steps in setting-up a prone IOA procedure for intracranial AVM/AVF surgery are proposed: (1) utilize an extended femoral sheath approach, (2) establish a localization landmark with an aneurysm clip and (3) avoid possible image interference from the non-radiolucent component of the head clamp.",
keywords = "Arteriovenous fistula, Arteriovenous malformation, Hybrid operating room, Intraoperative localization, Non-supine position",
author = "Chi Wang and Hsu, {Szu Kai} and Chang, {Chih Ju} and Chen, {Ming Hong} and Huang, {Chih Ta} and Huang, {Jing Shan} and Su, {I. Chang}",
year = "2019",
doi = "10.1007/s00062-019-00783-3",
language = "English",
journal = "Clinical Neuroradiology",
issn = "1869-1439",
publisher = "Springer Verlag",

}

TY - JOUR

T1 - Transfemoral Approach for Intraoperative Angiography in the Prone or Three-quarter Prone Position

T2 - A Revisited Protocol for Intracranial Arteriovenous Malformation and Fistula Surgery

AU - Wang, Chi

AU - Hsu, Szu Kai

AU - Chang, Chih Ju

AU - Chen, Ming Hong

AU - Huang, Chih Ta

AU - Huang, Jing Shan

AU - Su, I. Chang

PY - 2019

Y1 - 2019

N2 - Purpose: Among the different arterial accesses, the femoral access is the main approach for intraoperative angiography (IOA) performed in a prone position. Without a standardized protocol, however, the application of prone IOAs in intracranial arteriovenous malformation (AVM) or arteriovenous fistula (AVF) surgery remains limited by its procedural complexity. This study describes the detailed protocol for prone IOA through a transfemoral approach and highlights several refinements in preparing this procedure. Methods: This study retrospectively reviewed the intracranial or high cervical AVM/AVF surgical cases in which both resection and IOA were performed in the prone or three-quarter prone position. Extended femoral sheath approaches and radiolucent head clamps were used in all cases. An aneurysm clip, serving as a localization landmark in IOA, was routinely placed within the surgical field. The IOA imaging, clinical impact of IOA, and complications related to the procedure were recorded. Results: A total of six AVM and three AVF cases, operated on in the prone (n = 7) or three-quarter prone (n = 2) positions, were included. Multiple vessel injections were required in 66.7% of cases, and IOA was successfully performed in every intended vessel. All IOA images were adequate for interpretation, except for two cases in which the non-radiolucent component of the head clamp obscured the region of interest in the lateral views. Incomplete occlusion was identified in two patients, and the aneurysm clip provided precise guidance in localizing the residual nidus. Final IOA confirmed complete lesion removal in all cases, and there were no IOA-related complications. Conclusion: Three key steps in setting-up a prone IOA procedure for intracranial AVM/AVF surgery are proposed: (1) utilize an extended femoral sheath approach, (2) establish a localization landmark with an aneurysm clip and (3) avoid possible image interference from the non-radiolucent component of the head clamp.

AB - Purpose: Among the different arterial accesses, the femoral access is the main approach for intraoperative angiography (IOA) performed in a prone position. Without a standardized protocol, however, the application of prone IOAs in intracranial arteriovenous malformation (AVM) or arteriovenous fistula (AVF) surgery remains limited by its procedural complexity. This study describes the detailed protocol for prone IOA through a transfemoral approach and highlights several refinements in preparing this procedure. Methods: This study retrospectively reviewed the intracranial or high cervical AVM/AVF surgical cases in which both resection and IOA were performed in the prone or three-quarter prone position. Extended femoral sheath approaches and radiolucent head clamps were used in all cases. An aneurysm clip, serving as a localization landmark in IOA, was routinely placed within the surgical field. The IOA imaging, clinical impact of IOA, and complications related to the procedure were recorded. Results: A total of six AVM and three AVF cases, operated on in the prone (n = 7) or three-quarter prone (n = 2) positions, were included. Multiple vessel injections were required in 66.7% of cases, and IOA was successfully performed in every intended vessel. All IOA images were adequate for interpretation, except for two cases in which the non-radiolucent component of the head clamp obscured the region of interest in the lateral views. Incomplete occlusion was identified in two patients, and the aneurysm clip provided precise guidance in localizing the residual nidus. Final IOA confirmed complete lesion removal in all cases, and there were no IOA-related complications. Conclusion: Three key steps in setting-up a prone IOA procedure for intracranial AVM/AVF surgery are proposed: (1) utilize an extended femoral sheath approach, (2) establish a localization landmark with an aneurysm clip and (3) avoid possible image interference from the non-radiolucent component of the head clamp.

KW - Arteriovenous fistula

KW - Arteriovenous malformation

KW - Hybrid operating room

KW - Intraoperative localization

KW - Non-supine position

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