Intraprocedural arterial perforation during neuroendovascular therapy: Preliminary result of a dual-trained endovascular neurosurgeon in the neurosurgical hybrid operating room

Abstract

BackgroundIntraprocedural arterial perforation (IPAP) is a potentially dismal complication of neuroendovascular therapy with high mortality and morbidity rates. The management of IPAP with the techniques described has been well established, but rescue results from the dual-trained endovascular neurosurgeon in the neurosurgical hybrid operating room (OR) are rarely reported. Here, we report five cases of successful rescue of IPAP in the neurosurgical hybrid OR and compare them with other series. MethodsBetween December 2009 and December 2013, 146 intracranial neuroendovascular procedures were performed in the hybrid operating room of Taichung Veterans General Hospital. A total of five patients with IPAP were identified. Postoperative clinical outcome was evaluated by Glasgow Coma Scale scores and postoperative 3-month modified Rankin Scale. ResultsThe causes of the IPAP were coil protrusion (n = 3), microcatheter perforation (n = 1), and microwire penetration (n = 1). Two cases involved emergent ruptured aneurysms, while three cases occurred during elective procedures. Salvage treatment with emergent external ventricular drainage (EVD) was applied in all five cases. The average time-to-first-EVD was 16.25 min, and the average time-to-patent-EVD was 32.5 min. Postoperative 3-month outcome was good recovery (mRS ≤ 2) in all five cases. The zero mortality rate in our series is the most encouraging result in the published literature. ConclusionIPAP can be rescued successfully with an aggressive approach and quick conversion to backup surgery by a dual-trained endovascular neurosurgeon in the hybrid OR. The value of the hybrid OR in neuroendovascular therapy should be further investigated in the future.