Intra-arterial Indocyanine Green Angiography in the Management of Spinal Arteriovenous Fistulae

Abstract

We first present 2 cases of spinal arteriovenous fistulae (AVFs) successfully treated with the help of intra-arterial indocyanine green (ICG) angiography. To demonstrate the efficacy of intra-arterial ICG angiography in spinal AVFs compared with the role of intravenous ICG injection and intraoperative digital subtraction angiography (DSA). Intravenous ICG fluorescent angiography is an emerging intraoperative tool to recognize vascular anatomy. The technique is quite simple and provides real-time vascular hemodynamics in the operative field. However, it takes time for the ICG to be washed out; therefore, repeat studies are somewhat tedious and time consuming, especially in spinal AVFs with multiple shunts/drainer. In this setting, intraoperative DSA has still been the standard to confirm the complete obliteration, although this has a risk of radiation exposure and renal failure. Two patients, a 46-year-old man with spinal dural AVF at the cervicomedullary junction and a 68-year-old woman with spinal perimedullary AVF at the conus medullaris, were surgically treated with the help of intra-arterial ICG angiography. We introduced a catheter into the target artery and injected 0.05 mg ICG in 2 mL of normal saline in multiple, short intervals. This approach enabled us to detect the residual shunt/drainer and confirm complete obliteration. With this technique, a tiny amount of ICG was used in the operative field to clearly label only the affected vessels. Intraoperative DSA was not performed in these cases. These cases demonstrate that intra-arterial ICG angiography is a powerful tool for visualizing spinal AVFs in terms of addressing the disadvantages of intravenous ICG injection and intraoperative DSA.