Robot-assisted, monoplane C-arm angiography systems designed for hybrid operating rooms represent an alternative approach to neuroendovascular procedures. Conversely, non-computer-assisted monoplane systems or conventional biplane systems in angiography suites are widely established. This study aims to evaluate the effectiveness, safety and efficiency of a robotic C-arm angiography system in performing neuroendovascular interventions, including cerebrovascular digital subtraction angiography (DSA), embolization of the middle meningeal artery (MMA) in subdural hematoma, and mechanical thrombectomy for vessel occlusion. All patients undergoing DSA, MMA embolization, or mechanical thrombectomy between July 2020 and December 2024 were retrospectively included. Procedures were performed using a monoplane robotic C-arm system (ARTIS pheno, Siemens Healthineers, Munich, Germany) in a hybrid operating room. Clinical data, procedural details, and imaging outcomes were analyzed. Radiation exposure was assessed by fluoroscopy time, air kerma, and dose-area product (DAP). A total of 49 procedures were analyzed, including 28 DSAs, 6 MMA embolizations, and 15 mechanical thrombectomies. DSA and MMA embolization (EMMA grade ≥2) achieved 100% procedural success, while mechanical thrombectomies achieved successful reperfusion (mTICI ≥2b) in 93.3% of cases. Median procedure durations were 34.0 (IQR 18.0-45.0) minutes for DSA, 70.0 (IQR 28.0-126.0) minutes for MMA embolization, and 84.0 (IQR 67.0-106.0) minutes for mechanical thrombectomy. Median fluoroscopy times were 5.2 (IQR 2.9-11.5) minutes (DSA), 21.3 (IQR 8.8-36.5) minutes (MMA embolization), and 21.2 (IQR 18.5-42.9) minutes (mechanical thrombectomy). Median DAPs were 7262.5 (IQR 3867.8-11570.8) µGy·m² (DSA), 16135.5 (IQR 8244.2-18216.2) µGy·m² (MMA embolization), and 9875.2 (IQR 6524.3-18455.5) µGy·m² (mechanical thrombectomy). Additional 3D-angiography or cone-beam CT (CBCT) was associated with higher radiation exposure. Basic neuroendovascular procedures can be safely and efficiently performed using a monoplane robotic C-arm in a hybrid operating room, achieving procedural success and radiation exposure levels comparable to conventional biplane systems.

The aim of this study was to develop and internally validate a phase-updating nursing predictive assessment tool based on baseline patient-surgical risk and modifiable nursing processes for use before surgery and after positioning in the hybrid digital subtraction angiography operating room. This single-center retrospective cohort included inpatient adults undergoing their first procedure in the hybrid operating room, with surgery as the unit of analysis and follow-up to 72 h postoperatively. The outcome was a composite endpoint of position-related complications. Missing predictor data were handled using multiple imputation (m = 10), and extraction consistency was assessed with Cohen κ and intraclass correlation coefficients. Candidate variables from univariable screening plus prespecified variables entered least absolute shrinkage and selection operator regression, followed by multivariable logistic modeling and nomogram construction with threshold-based risk stratification. Model performance was evaluated by area under the curve, calibration intercept and slope, Brier score, bootstrap internal validation, and decision curve analysis. A total of 1,936 cases were analyzed, and the composite outcome occurred in 10.23%. Maximum missingness of key variables was 3.25%, and extraction consistency was good (κ ≥ 0.86, intraclass correlation coefficient ≥ 0.89). Twelve predictors were retained; pressure-point protection and intraoperative position checks were protective (odds ratio 0.68-0.71). The baseline model had an area under the curve of 0.74/0.72 (apparent/corrected), and the full model achieved 0.79/0.77. The optimism-corrected calibration slope was 0.947, the intercept was 0.004, and the Brier score was 0.085. This tool showed stable discrimination, calibration, and net benefit on internal validation. Nursing process variables added value, and the tool may support preoperative assessment and post-positioning risk updating, pending external validation.

ABSTRACTBackgroundIntraoperative C‐arm imaging is essential in orthopaedic and trauma surgery, particularly with the increasing use of minimally invasive techniques. Conventional repositioning is performed by non‐scrubbed staff, while robotic imaging systems are mainly limited to hybrid operating rooms. This study presents the first clinical experience with a fully motorised, self‐driving mobile 3D‐C‐arm.MethodsIn this prospective, single‐center study, 300 procedures were analyzed using device log data and perioperative parameters to assess imaging workflow and system performance.ResultsOf 300 procedures, 279 were included. Mean procedure time was 104.7 ± 57.4 min, with a C‐arm operation time of 31.9 ± 29.1 min, corresponding to a C‐arm operation ratio (COR) of 35.2%. Automated positioning accounted for 30.7% of movements, and 37.9% of images were acquired from stored positions.ConclusionThe system enabled sterile‐field control and demonstrated potential to support intraoperative imaging workflow. Further comparative studies are required to evaluate its clinical impact.

Delays in mechanical circulatory support (MCS) for cardiogenic shock can be critical. However, timely access to a hybrid operating room or C-arm fluoroscopy for urgent axillary Impella 5.5 (Abiomed, Danvers, MA) implantation remains a barrier. To address this, we developed a fluoroscopy-free axillary Impella 5.5 implantation technique using transesophageal echocardiography (TEE) guidance. From January 2023 to November 2024, 19 adults underwent the procedure. A preoperative flowchart ensured appropriate selection, with the right axillary artery as the preferred access. Transesophageal echocardiography-guided pigtail advancement, valve crossing, and device positioning. All implantations (100%) were successful without conversion to fluoroscopy-guided or ECMO. There were no strokes or major complications. All patients had optimal positioning and rapid hemodynamic improvement. These findings support the feasibility and safety of TEE-guided, fluoroscopy-free Impella 5.5 implantation. It offers a significant benefit for earlier implantation of MCS in patients with cardiogenic shock, especially in settings where limited or delayed access to fluoroscopic imaging resources is a barrier to timely intervention.

Surgical management of a lenticulostriate artery aneurysm and an associated initially less-appreciated arteriovenous malformation: two-dimensional video.

Thin-slice high-resolution computed tomography (CT) has improved the detection of small pulmonary nodules, increasing the demand for minimally invasive diagnostic and therapeutic resection. While lobectomy with lymph node dissection remains the standard surgical approach for many patients with resectable non-small cell lung cancer, accumulating evidence supports sublobar resection for selected small, peripheral, and ground-glass-dominant lesions when sufficient margins are achievable. In thoracoscopic and robotic surgery, localization of nodules ≤10 mm or lesions located >5 mm from the pleural surface can be challenging, and failure to identify the target may lead to conversion, larger resection than intended, or prolonged operative time. Several localization strategies have been developed, including CT-guided percutaneous wire/coil/dye marking, bronchoscopic dye mapping, and virtual-assisted lung mapping (VAL-MAP), robotic-assisted bronchoscopic dye or fiducial localization, radiofrequency identification microtag systems (Surgical Real-Time FInger Navigation and Detection) that provide real-time depth information, and single-stage intraoperative CT-guided marking and resection in hybrid operating rooms. This review synthesizes representative evidence and published outcome ranges, and compares workflows, marker-to-lesion precision metrics, complication profiles, operational burden, and cost structures. We emphasize the practical contrast between two-stage and single-stage workflows, the access-route differences between transthoracic and transbronchial techniques, and the need to report localization-to-incision "time at risk". We also present an expert-consensus decision algorithm aimed at facilitating tailored selection of localization strategies for modern minimally invasive thoracic surgery.

Implementation of dual-device direct current cardioversion to restore sinus rhythm during hybrid antiarrhythmic cardiac surgery for persistent atrial fibrillation: A case series and insights from the hybrid operating room.

A single-center retrospective analysis of keyhole clipping for intracranial aneurysms in hybrid operating room.

Carotid-cavernous fistulas (CCFs) are abnormal connections between the carotid artery and the cavernous sinus.1 Although transorbital access via the superior ophthalmic vein is well described, percutaneous access via the inferior ophthalmic vein (IOV) is rarely reported.2 A 78-year-old woman presented with a 1-year history of left proptosis, pulsatile tinnitus, and more recent visual changes. Digital subtraction angiography revealed a Barrow type D CCF with drainage into the left sylvian vein and IOV. Due to isolated IOV drainage, direct transorbital puncture was performed in a hybrid operating room with the patient's head immobilized in a Mayfield head holder. Brainlab Elements Image Fusion Angio was used for preoperative trajectory planning and intraoperative navigation, providing complementary verification of entry point and trajectory, whereas syngo Needle Guidance by Siemens was used for real-time needle localization and alignment. Embolization was completed using coils and Onyx to achieve a complete angiographic cure of the fistula. Postoperatively, the patient reported marked improvement in vision. Indirect CCFs with isolated IOV drainage may necessitate direct transorbital access when conventional routes are not feasible.

Real-time three-dimensional robotic C-arm navigation for ventriculoperitoneal shunt placement: a single-center retrospective study.

The aim of this operation is to stabilise aT-type acetabular fracture against secondary dislocation and to restore the patient's preoperative functionality. An 88-year-old patient with severe pain and immobility due to aT-type acetabular fracture (Letournel & Judet: associated fracture; AO: 62B2). General surgical contraindications. This surgery was performed in a3D-Navigation Hybrid Operating Room, the Robotic Suite (Brainlab, Munich, Germany). The setup includes anavigation unit (Curve Navigation System) amovable robotic 3D cone beam computed tomography unit (Loop-X), arobotic arm (Cirq Arm System), 3D mixed reality glasses (for planning), and awall monitor (Buzz). Astep-by-step video is available online. Immediate full weight-bearing, active and passive joint mobilisation through physiotherapy on the first postoperative day, pain medication as required. Navigated surgeries of the pelvis (ring and acetabulum) have become standard practice, while robotic assistance is increasingly used, demonstrating very good outcomes and promising accuracy rates.

Background/Objectives: Intraoperative cone-beam computed tomography (CBCT) can detect residual fragments (RFs) during percutaneous nephrolithotomy (PCNL), enabling immediate removal and improving stone-free status. However, CBCT requires a hybrid operating room (OR), which is often limited in availability. This study explores patient and stone characteristics associated with CBCT eligibility and develops an exploratory treatment-selection model estimating stone-free probabilities conditional on CBCT use. Methods: We performed a retrospective study of a previously conducted randomized controlled trial evaluating intraoperative CBCT during PCNL in a tertiary care center. We compared CBCT-eligible cases versus ineligible cases, and cases achieving grade C (≤4 mm) stone-free status versus those with RFs. A multivariate exploratory treatment-selection model was developed using the strongest potential predictors of stone-free status. Internal validation was performed using bootstrapping. The model was also assessed for predicting grade A (0 mm) stone-free status. Results: The only significant difference between CBCT-eligible (n = 160) and ineligible (n = 60) cases was stone composition (p = 0.022). The final model included intraoperative CBCT (p = 0.003), stone size (p = 0.024), and composition (p = 0.044). Model-based estimates suggested smaller differences in predicted stone-free probabilities with CBCT in solitary stones. The AUC was 0.81 (95% CI: 0.73–0.88) for grade C and 0.75 for grade A (95% CI: 0.67–0.82) outcomes. Internal validation demonstrated moderate optimism, indicating potential overfitting. Conclusions: This exploratory treatment-selection model estimates conditional stone-free probabilities with and without CBCT. The findings suggest variation in expected benefit across stone characteristics but should be considered hypothesis-generating. The model is not intended for clinical decision-making and requires external validation before implementation.

Arterial angiography remains the gold standard for the assessment of cerebrovascular anatomy and pathology. However, when arterial access is higher risk (patients with extreme tortuosity, type 4 Ehlers Danlos Syndrome, or the young pediatric population), and for long-term follow-up or intraoperative scenarios, intravenous 3-dimensional digital subtraction angiography (IV 3D-DSA) is an acceptable substitute. We assessed our experience in consecutive IV 3D-DSA procedures. Five hundred twenty-eight adult and 21 pediatric IV 3D-DSAs were performed at our institution on 2 state-of-the-art systems from January 2019 to March 2025. Imaging obtained on older angiography systems are not included. The cone-beam computed tomography (CBCT) data were reconstructed and displayed as 3D-DSA, CBCT without contrast, and CBCT angiography. Data were analyzed for indication, conversion to intra-arterial angiography, use of anesthesia, radiation dose, and complications. The primary indication in 408/528 adult and 9/21 pediatric patients was aneurysm evaluation, initial, postoperative, or follow-up. Other indications included vascular malformations, postoperative after revascularization surgeries, and other pathologies such as extracranial carotid disease and intracranial atherosclerotic disease. Seven of the 528 adult cases were significantly limited by motion artifact (1.3%), but only 3 of these were considered nondiagnostic (0.6%). Seventy-one adult and 2 pediatric acquisitions were performed intraoperatively in the hybrid operating room. 20/21 pediatric cases required general anesthesia. Eighty-six adult cases were performed under anesthesia, although most of these were performed intraoperatively under the same anesthetic as the index operation. There were no significant complications reported. With the newer, higher resolution, semirobotic biplane systems, IV 3D-DSA has become a tool in the angiography suite for rapid vascular assessment. It offers increased spatial resolution when compared with multidetector computed tomography, making it well suited to evaluate vasculature and endovascular devices, is noninvasive compared with catheter angiography, and can be used for intraoperative assessment of treatment.

Pericardiocentesis is a life-saving intervention in the treatment of cardiac tamponade. This study aims to evaluate the safety, efficacy, and short-term outcomes of fluoroscopy-guided pericardiocentesis performed by cardiovascular surgeons in a hybrid operating room setting.Data from 64 patients who underwent fluoroscopy-guided percutaneous drainage for symptomatic pericardial effusion in a hybrid operating room between January 2020 and December 2024 were analyzed retrospectively. Procedures were performed using a standard subxiphoid approach and a pigtail catheter.The etiology was malignancy in 31.2% (n = 20) of the patients. The median maximum effusion diameter measured on preoperative echocardiography was 24 mm (interquartile range [IQR]: 20-28 mm), which decreased significantly to 7 mm (IQR: 5-9 mm) on postoperative evaluation (p < 0.001). The minor complication rate was 1.5% (n = 1, pneumothorax). No surgical conversion (sternotomy) was required during the procedures. Reintervention was required in only two patients (3.1%) during the 3-month follow-up.Fluoroscopy-guided pericardiocentesis performed under hybrid operating room conditions represents a safe option with low complication and recurrence rates, even in high-risk groups such as malignancy. The real-time anatomical visualization provided by fluoroscopy, combined with the surgical infrastructure of the hybrid environment, provides a feasible workflow for cardiac surgeons. However, these findings need to be supported by more extensive and comparative studies.

Improving Transcatheter Aortic Valve Implantation Efficiency and Outcomes in the Canadian Healthcare Environment.

Enhanced Recovery After Surgery (ERAS) pathways have been adapted for open and lower extremity vascular surgery and increasingly guide perioperative care for older adults. However, little is known about how perioperative nurses implement ERAS-consistent and geriatric-focused practices for older patients undergoing open and hybrid aortic procedures, particularly in hybrid operating room settings and in Chinese hospitals, where pathway maturity and geriatric integration may vary across centres. To describe perioperative nurses' implementation of ERAS-consistent and geriatric-focused nursing practices for older adults undergoing open and hybrid aortic vascular surgery in China, and to identify nurse- and organisation-level factors associated with higher implementation, with attention to modifiable determinants (training, ERAS pathways, staffing). Registered nurses working in operating theatres/hybrid operating rooms, post-anaesthesia care units, intensive care/high-dependency units, vascular surgical wards and pre-assessment clinics in eight tertiary general hospitals in Shanxi Province, China, were surveyed between March and July 2024. The Geriatric-Focused Vascular ERAS Nursing Practices Questionnaire, developed from ERAS/SVS guidelines and geriatric surgery literature, measured nurse-reported implementation across perioperative domains, geriatric-focused elements, attitudes and perceived barriers. The instrument underwent expert review, pilot testing and internal consistency assessment, while more advanced psychometric testing was beyond the scope of this initial multicentre study. Data were analysed using descriptive statistics, group comparisons and multivariable linear regression; free-text responses were examined using inductive qualitative content analysis. The study was conceptually informed by a Donabedian structure-process-outcome framework and a capability-opportunity-motivation perspective on behaviour change. Of 640 eligible nurses, 428 provided analysable responses (usable response rate 66.9%). The global ERAS implementation score (1-5) was 3.41 (SD 0.49). Implementation was highest for intraoperative/post-anaesthesia practices (3.82, SD 0.61) and preoperative education/optimisation (3.63, SD 0.72), and lowest for frailty and cognitive/delirium assessment (2.71, SD 0.81). Routine frailty assessment was reported by 23.4% and routine use of structured delirium screening tools by 30.8%. Higher implementation was independently associated with ERAS-specific training (B = 0.28, p < 0.001), geriatric/frailty training (B = 0.12, p = 0.008), working in hospitals with a formal ERAS pathway (B = 0.24, p < 0.001), higher perceived staffing adequacy (B = 0.09, p = 0.004), and greater experience (B = 0.04 per 5 years, p = 0.012) (adjusted R2 = 0.38). Qualitative findings highlighted ERAS as an "ideal rather than daily reality", challenges in technology-dense environments, fragmented responsibilities, and the need for leadership and tailored education. Perioperative nurses in these tertiary hospitals reported moderate implementation of ERAS-consistent care for older adults undergoing open and hybrid aortic vascular surgery, with substantial gaps in frailty assessment, delirium screening and geriatric-tailored practices. These gaps are clinically important because they may limit timely risk recognition and tailoring of perioperative care in a high-risk older surgical population. ERAS-specific and geriatric training, hospital-level ERAS pathways, perceived staffing adequacy and experience were associated with higher implementation and represent important modifiable targets, although causal relationships cannot be inferred from this cross-sectional survey.

Surgical bailout during transcatheter aortic valve replacement (TAVR) is rare but highly critical. We evaluated the impact of hospital infrastructure, procedural setting, timing metrics, and haemodynamic stability on patients requiring emergent surgical bailout. A single-centre analysis was conducted on consecutive TAVR cases requiring emergent surgical bailout between 2009 and 2024. Two eras were compared: Era 1 (2009-2016), with procedures performed in a conventional catheterisation laboratory (CCL) requiring transfer to a distant operating room, and Era 2 (2017-2024), using a purpose-built hybrid operating room (HOR) with all disciplines on site. The primary endpoint was in-hospital mortality. Secondary endpoints included time to extracorporeal life support (ECLS) initiation and surgical incision. Of 3039 TAVR procedures, 16 patients (0.53%) required surgical bailout (10 in Era 1, 6 in Era 2). In-hospital mortality was 100% in the CCL group versus 33.3% in the HOR group (P < 0.01). While time to ECLS was similar, time to surgical intervention was significantly shorter in the HOR group. All HOR patients received definitive surgical treatment, whereas 60% of CCL patients died before surgery could be initiated. Haemodynamic instability prior to conversion differed significantly between groups. Surgical bailout during TAVR is rare, but associated mortality remains high. Bailout performed in a HOR was associated with shorter delays to surgical incision and improved outcomes, with haemodynamic stability at the time of conversion emerging as an important factor associated with survival. These findings highlight the potential relevance of minimising time to surgery through optimised infrastructure, such as a HOR.

Intracranial mycotic aneurysms are rare, representing only 0.7%-5.4% of all intracranial aneurysms, and typically arise from septic emboli secondary to infective endocarditis. Large-vessel occlusion due to a septic embolus is exceedingly uncommon and carries high morbidity. A 29-year-old man with methicillin-resistant Staphylococcus aureus endocarditis and intravenous drug use presented with intracerebral and subarachnoid hemorrhage. CT angiography revealed a left parieto-occipital hematoma with midline shift. An emergency craniotomy for hematoma evacuation exposed a ruptured distal middle cerebral artery (MCA) mycotic aneurysm, which was clipped, and pathological analysis confirmed abscess formation within the aneurysm wall. Despite antibiotic therapy, a new distal MCA aneurysm developed within an abscess cavity. Cerebral angiography later demonstrated M1 occlusion requiring mechanical thrombectomy, achieving partial reperfusion consistent with Thrombolysis in Cerebral Infarction grade 2a. The persistent abscess and aneurysm required Onyx embolization and abscess drainage in a hybrid operating room. Sequential mycotic aneurysms with concurrent large-vessel occlusion and abscess formation represent a rare and aggressive manifestation of septic emboli. Successful management depends on coordinated microsurgical clipping, endovascular embolization, thrombectomy, and abscess evacuation. Early recognition of evolving vascular pathology and combined surgical-endovascular approaches improve outcomes in infective mycotic aneurysm-related cerebrovascular disease. https://thejns.org/doi/10.3171/CASE25902.

Retraction: Image-guided procedures in the hybrid operating room: A systematic scoping review

BACKGROUND Internal jugular vein catheterization is a primary vascular access method for hemodialysis; however, it carries a risk of complications. Common adverse events include arterial puncture, hematoma, and pneumothorax; rarer but more serious events involve catheter malposition into major arteries. Despite real-time ultrasound guidance, anatomic factors, technical considerations, and patient-specific characteristics may contribute to these adverse outcomes. CASE REPORT A 64-year-old man with end-stage renal disease and decompensated heart failure required urgent dialysis. During ultrasound-guided placement of a 12.5-Fr dual-lumen catheter, the sheath inadvertently traversed the jugular vein, entered the right subclavian artery, and advanced to the aortic arch. Computed tomography angiography confirmed the catheter course. In a hybrid operating room, the arterial injury was successfully managed using an endovascular suture device. This approach achieved hemostasis without additional venous injury and avoided the need for open surgical repair. No evidence of impaired intracranial blood flow was observed during follow-up. Dialysis was resumed via femoral access the following day; the patient was discharged without complications. This case highlights a rare but life-threatening complication of a routine procedure. CONCLUSIONS Real-time ultrasound guidance does not eliminate the risk of serious catheter misplacement during internal jugular vein cannulation. When inadvertent subclavian artery cannulation occurs, an endovascular suture device may provide a rapid and minimally invasive solution avoiding further venous compromise and posing no risk to cerebral perfusion. These findings support consideration of endovascular closure as an option for the management of iatrogenic arterial injuries, particularly in high-risk patients who are unsuitable for major surgery.