Intraoperative Digital Subtraction Angiography Research Articles

Digital subtraction angiography of intrahepatic portal vein as the key visualization for mesoportal shunting in children with extrahepatic portal vein obstruction

Аn early consideration in pediatric patients with extrahepatic portal vein obstruction (EHPVO) is to be given for mesoportal shunt. A careful investigation is required to prove intrahepatic portal system patency. Conventional noninvasive imaging is not adequately reliable in assessing patency of the intrahepatic portal venous system. Retrograde portography in children brings additional invasive procedure. Antegrade, direct intraoperative digital subtraction angiography for mesoportal shunt feasibility assessment is poorly presented in literature. Aim - to improve the rate of success of mesoportal shunting in children with EHPVO by analyzing our own experience in intraoperative digital subtraction angiography of the intrahepatic branches of the portal vein for the final assessment of the mesoportal shunting feasibility. Materials and methods. 7 pediatric patients with EHPVO were selected for the study. Angiographies and surgeries in selected patients were performed within single center in a period from May 2022 to July 2023. Mean follow up of successful mesoportal shunting was 12.38±1.46 months. Results. All patients were males. Men age at surgery was 8.71±1.72 years. 5 (71.4%) patients manifested bleeding episodes as the first sign of portal hypertension. In all patients ultrasound revealed splenomegaly and suspected portal hypertension for reduced volumetric portal flow. All 7 patients had high grade. Liver function was normal in all patients, and in none thrombophilia was confirmed. CT scans suspected patent left intrahepatic branch (Rex-zone). Digital subtraction angiography approved mesoportal shunt feasibility in 4 (57.1%) patients. The follow up period was 13.5±2.9 months. Conclusions. Digital subtraction angiography of intrahepatic portal vein is effective visualization method to achieve with radiologic evidence of intrahepatic portal branches patency and make the decision on mesoportal shunting when favorable anatomy proved. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Image fusion guidance for left subclavian artery in situ fenestration during thoracic endovascular repair.

To evaluate the feasibility and clinical benefit of utilizing image fusion for thoracic endovascular repair (TEVAR) with in situ fenestration (ISF-TEVAR). Between January 2020 and December 2020, we prospectively collected 18 consecutive cases with complex thoracic aortic lesions who underwent image fusion guided ISF-TEVAR. As a control group, 18 patients were collected from historical medical records from June 2019 to December 2019. The fusion group involved the use of 3D fusion of CTA and fluoroscopic images for real-time 3D guidance, and the control group involved the use of only regular fluoroscopic images for guidance. The total contrast medium volume, hand-injected contrast medium volume, overall operative time, radiation dose and fluoroscopy time were compared between the two groups. Accuracy was measured based on preoperative CTA and intraoperative digital subtraction angiography. 3D fusion imaging guidance was successfully implemented in all patients in the fusion group. Hand-injected contrast medium volume and overall operative time were significantly lower in the fusion group than in the control group (p = .028 and p = .011). Compared with the control group, the fusion group showed a significant reduction in time and radiation dose-area product (DAP) for fluoroscopy (p = .004 and p = .010). No significant differences in total radiation dose (DAP) or total contrast medium volume were observed (p = .079 and p = .443). Full accuracy was achieved in 8 cases (44%), with a mean deviation of 2.61mm ± 3.1 (range 0.0-8.4mm). 3D image fusion for ISF-TEVAR was associated with a significant reduction in hand-injected contrast medium, time and radiation exposure for fluoroscopy and overall operative time. The image fusion guidance showed potential clinical benefits towards improved treatment safety and accuracy for complex thoracic endovascular interventions.

Comparison of IMD and ICG videoangiography in combined bypass surgery: a single-center study.

Superficial temporal artery-middle cerebral artery (STA-MCA) bypass combined with an encephaloduromyosynangiosis (EDMS) had gained significant role in treating chronic cerebral ischemia. Invasiveness and costs of intraoperative digital subtraction angiography (DSA) limited its application in operations. To find the reliable parameters for determining bypass patency with intraoperative micro-Doppler (IMD) sonography and compare the diagnostic accuracy of indocyanine green (ICG) videoangiography with IMD in combined bypass. One hundred fifty bypass procedures were included and divided into patent and non-patent groups according to postoperative computed tomography angiography (CTA) within 72h. The surgical process was divided into four phases in the following order: preparation phase (phase 1), anastomosis phase (phase 2), the temporalis muscle closure phase (phase 3), and the bone flap closure phase (phase 4). The IMD parameters were compared between patent and non-patent groups, and then compared with the patency on CTA by statistical analyses. IMD with CTA, ICG videoangiography with CTA,IMD with ICGvideoangiography were performed to assess bypass patency. The agreement between methods was evaluated using kappa statistics. No significant differences of baseline characteristics were found between patent and non-patent group. Parameters in the STA were different between patent and non-patent groups in phases 2, 3, and 4. In patent group, Vm was apparently higher and PI was lower in phases 2, 3, and 4 compared with phase 1 (P < .001). In non-patent group, no differences of Vm and PI were found within inter-group. The best cutoff value of IMD in the STA to distinguish patent from non-patent bypasses was Vm in phase 4 > 17.5cm/s (sensitivity 94.2%, specificity 100%). In addition, the agreement for accessing bypass patency was moderate between ICGvideoangiography and CTA (kappa = 0.67), IMD and ICG videoangiography (kappa = 0.73), and good between IMD and CTA (kappa = 0.86). ICG videoangiography could directly display morphology changes of bypass. IMD could be used for providing half-quantitative parameters to assess bypass patency. Vm in phase 4 > 17.5cm/s suggesting the patency of bypass on CTA would be good. Also, compared with ICG videoangiography, IMD had more accuracy.

3D/2D Vessel Registration Based on Monte Carlo Tree Search and Manifold Regularization.

The augmented intra-operative real-time imaging in vascular interventional surgery, which is generally performed by projecting preoperative computed tomography angiography images onto intraoperative digital subtraction angiography (DSA) images, can compensate for the deficiencies of DSA-based navigation, such as lack of depth information and excessive use of toxic contrast agents. 3D/2D vessel registration is the critical step in image augmentation. A 3D/2D registration method based on vessel graph matching is proposed in this study. For rigid registration, the matching of vessel graphs can be decomposed into continuous states, thus 3D/2D vascular registration is formulated as a search tree problem. The Monte Carlo tree search method is applied to find the optimal vessel matching associated with the highest rigid registration score. For nonrigid registration, we propose a novel vessel deformation model based on manifold regularization. This model incorporates the smoothness constraint of vessel topology into the objective function. Furthermore, we derive simplified gradient formulas that enable fast registration. The proposed technique undergoes evaluation against seven rigid and three nonrigid methods using a variety of data - simulated, algorithmically generated, and manually annotated - across three vascular anatomies: the hepatic artery, coronary artery, and aorta. Our findings show the proposed method's resistance to pose variations, noise, and deformations, outperforming existing methods in terms of registration accuracy and computational efficiency. The proposed method demonstrates average registration errors of 2.14 mm and 0.34 mm for rigid and nonrigid registration, and an average computation time of 0.51 s.

Unilateral approach for bilateral clipping of posterior communicating artery aneurysms in a hybrid operating room: A technical note.

Bilateral posterior communicating (pComm) artery aneurysms represent only 2% of mirror intracranial aneurysms. Usually, these are surgically approached through bilateral craniotomies for clipping. We present the case of a 50-year-old female presenting with headache and horizontal diplopia. Neurological examination revealed a left oculomotor palsy, with no other neurological deficits. Imaging studies revealed bilateral aneurysmatic lesions in both internal carotid arteries (ICA). A conventional left pterional approach was planned in order to treat the symptomatic aneurysm, and, if deemed feasible, a contralateral clipping through the same approach. The procedure was performed in a hybrid operating room (HOR), performing an intraoperative digital subtraction angiography (DSA) and roadmapping assistance during dissection and clipping. Transoperatively, a post-fixed optic chiasm was identified, with a wide interoptic space, which allowed us to perform the contralateral clipping through a unilateral approach. This technique for clipping bilateral pComm aneurysms can be performed when the proper anatomical features are met.

Evaluation of Serial Intra-Arterial Indocyanine Green Videoangiography in the Surgical Treatment of Cranial and Craniocervical Junction Arteriovenous Fistulae: A Case Series.

Intravenous indocyanine green (IV-ICG) videoangiography is commonly performed to detect blood flow in the microscopic view. However, intra-arterial ICG (IA-ICG) videoangiography provides high-contrast imaging, repeatability within a short period of time, and clear-cut separation of the arterial and venous phases compared with IV-ICG. These features are useful for detecting retrograde venous drainage (RVD) and shunt occlusion in arteriovenous fistulae (AVF) surgery. This study aimed to investigate whether IA-ICG videoangiography can be repeatable within a short period of time and be useful for detecting RVD and shunt occlusion in cranial- and craniocervical junction (CCJ)-AVF surgery. Between January 2012 and December 2022, 50 patients were treated with endovascular or surgical intervention for cranial- and CCJ-AVF at Tokushima University Hospital. Of these, 5 patients (6 lesions) underwent open surgery with IA-ICG videoangiography in a hybrid operating room. We analyzed the data of these 5 patients (6 lesions). There were 4/patient (median, range 2-12) and 3.5/lesion (median, range 2-10) intraoperative IA-ICG runs. IA-ICG videoangiography detected RVD in all patients. Clearance of IA-ICG-induced fluorescence was achieved within 30 seconds in all patients at each region of interest. After the disconnection of the fistulae, IA-ICG videoangiography and intraoperative digital subtraction angiography (DSA) confirmed the disappearance of RVD in all patients. There were no complications associated with IA-ICG videoangiography. This study showed that IA-ICG videoangiography is repeatable within a short period of time before and after obliteration and can be useful for detecting RVD and shunt occlusion in cranial- and CCJ-AVF surgery. IA-ICG videoangiography also allows intraoperative DSA studies in a hybrid operating room. Considering the recent advancements in hybrid operating rooms, combining IA-ICG videoangiography with intraoperative DSA is a useful strategy for cranial- and CCJ-AVF surgery.

Association Between Cerebral Angiography and Asymmetrical Cortical and Deep/Medullary Vein Signs on T2 Star Magnetic Resonance Imaging in Patients with Hyperacute Horizontal Segment of the Middle Cerebral Artery Occlusion

When treating acute ischemic stroke patients, evaluation of collateral flow to the ischemic area is essential. Blood-oxygen-level-dependent imaging, including T2 star (T2∗), can identify elevated deoxyhemoglobin levels, reflecting an increase in the oxygen extraction fraction. Prominent veins on T2∗ represent increased deoxyhemoglobin and cerebral blood volume. This study compared asymmetrical vein signs (AVSs) on T2∗ and digital subtraction angiography findings during mechanical thrombectomy (MT) in patients with hyperacute middle cerebral artery occlusion. Clinical and imaging data of 41 patients with occlusion of the horizontal segment of the middle cerebral artery who underwent MT were collected. Patients were divided into 2 groups based on angiographic occlusion sites as: proximal and distal to the lenticulostriate artery (LSA). AVSs on T2∗ were divided into asymmetrical cortical vein sign (cortical AVS) and asymmetrical deep/medullary vein sign (deep/medullary AVS), and were compared with the findings of intraoperative digital subtraction angiography. Twenty-seven patients had AVSs. Cortical AVS was the only parameter with a significant association with poor angiographic collateral supply. In terms of occlusion site, deep/medullary AVS was the only parameter with a significant association with occlusion proximal to the LSA. In patients with occlusion of the horizontal segment of the middle cerebral artery, presence of the cortical AVS on T2∗ suggests a poor angiographic collateral supply, while presence of the deep/medullary AVS suggests impaired blood flow to the basal ganglia through LSAs. Both these signs contribute to poor outcomes in patients undergoing MT.

Intraoperative DSA-guided minimal approach for craniocervical junction DAVFs obliteration.

Dural arteriovenous fistulas (DAVFs) are a group of diseases involving problematic shunts between dural arteries and venous structures such as sinuses, meningeal veins, or even cortical veins. To focus on craniocervical junction dural arteriovenous fistulas (DAVFs), we introduce a minimally invasive technique with midline incision combined with intraoperative digital subtraction angiography (DSA). This hybrid technique can minimize the incision wound to an average of 6 cm which leads to less destruction and lower risk of adverse events. Using this minimally invasive approach, surgical obliteration was achieved in 6 patients with craniocervical junction DAVFs. A minimal midline incision was made over the C1-2 level, measuring approximately 5 to 7 cm in length. C1 hemilaminectomy was performed for DAVF obliteration followed by intraoperative DSA for confirmation of complete obliteration. Among these 6 patients, the radiculomedullary artery was the most common feeding artery. The mean length of the operation (including DSA performance) was 6.5 ± 1.4 h. None of these cases showed cerebrospinal fluid leakage or exacerbation of neurological symptoms after the operation. Using intraoperative DSA, the minimally invasive technique offers more precise but less destructive access than conventional far lateral suboccipital craniotomy. Most importantly, intraoperative DSA provided verification of complete closure for shunts that could not be examined for indocyanine green (ICG) dye because the microscope did not have a clear line of sight. In our experience, this technique shows encouraging results of fistula obliteration.

Multi-mode information fusion navigation system for robot-assisted vascular interventional surgery

BackgroundMinimally invasive vascular intervention (MIVI) is a powerful technique for the treatment of cardiovascular diseases, such as abdominal aortic aneurysm (AAA), thoracic aortic aneurysm (TAA) and aortic dissection (AD). Navigation of traditional MIVI surgery mainly relies only on 2D digital subtraction angiography (DSA) images, which is hard to observe the 3D morphology of blood vessels and position the interventional instruments. The multi-mode information fusion navigation system (MIFNS) proposed in this paper combines preoperative CT images and intraoperative DSA images together to increase the visualization information during operations.ResultsThe main functions of MIFNS were evaluated by real clinical data and a vascular model. The registration accuracy of preoperative CTA images and intraoperative DSA images were less than 1 mm. The positioning accuracy of surgical instruments was quantitatively assessed using a vascular model and was also less than 1 mm. Real clinical data used to assess the navigation results of MIFNS on AAA, TAA and AD.ConclusionsA comprehensive and effective navigation system was developed to facilitate the operation of surgeon during MIVI. The registration accuracy and positioning accuracy of the proposed navigation system were both less than 1 mm, which met the accuracy requirements of robot assisted MIVI.

Effect analysis of the modified wire-loop snare technique in retrieving severely tilted inferior vena cava filters

Objective: To examine the application effect of the modified wire-loop snare technique in retrieving severely tilted inferior vena cava filters (IVCF). Methods: The clinical data of 18 patients (12 males and 6 females, aged (62.1±13.1) years (range: 29 to 78 years)) who underwent the modified wire-loop snare technique to retrieve IVCF at the Affiliated Hospital of Qingdao University, Qingdao Eighth People's Hospital, and Jimo District Hospital of Traditional Chinese Medicine from November 2017 to April 2022 were retrospectively analyzed. The applied filters included drum-type filters (OptEase in 7 cases, Aegisy in 2 cases) and conical filters (Celect in 6 cases and Denali in 3 cases). Preoperative CT angiography and intraoperative digital subtraction angiography showed that the filter was severely tilted and the hook was covered by hyperplastic intima of the vena cave vein. A modified wire-loop snare technique was used to retrieve drum-type filters and conical filters via femoral and jugular vein approaches, respectively. After successful puncture, the long sheath was placed, the 4 F (1 F≈0.33 mm) vertebral catheter and a snare were inserted through the long sheath, and the 5 F pigtail catheter was inserted simultaneously to guide a 0.035 inch soft guide-wire (260 cm in length) to pass through the top of the filter and turning back. The tip of the soft guide-wire was snared by the vertebral catheter and pulled out of the sheath. The 4 F vertebral catheter was inserted following the tip of the guide-wire to form a wire-loop using the vertebral catheter and the pigtail catheter. After fixing the tip and tail of the soft guide-wire in vitro, the long sheath was pushed forward to cut the hyperplastic intima and the hook was pulled away from the vena cava wall to retrieve the filter under the support of two catheters. Results: The filters were successfully retrieved in 17 cases, the operation time was (25.5±8.7) minutes (range: 15 to 45 minutes), no complication occured. The hook of one filter (Celect) penetrated out of the vena vava wall and the wire-loop could not pull the hook back into the vena cava. Then the filter was removed by laparotomy. Conclusion: The modified wire-loop snare technique could retrieve the severely tilted retrivable drum-type filters and conical filters, even when serve adhesion exists between the filter and the vena cava wall.

The additional value of high-resolution vessel wall imaging in screening suitable chronic internal carotid artery occlusion candidates for endovascular recanalization: comparison with digital subtraction angiography.

High-resolution vessel wall imaging (HR-VWI) can provide information about exact occluded length, etiology, and the presence of intraluminal thrombus or residual cavity. To investigate the extra value of HR-VWI in screening patients with chronic internal carotid artery occlusion (CICAO) for recanalization suitability in comparison with digital subtraction angiography (DSA). We retrospectively reviewed patients who underwent endovascular recanalization with no internal carotid artery signal on magnetic resonance angiography (MRA) and whose both preoperative DSA and HR-VWI data were available. Patients were classified into type I (focal occlusion distal to ophthalmic artery), type II or III (occlusion proximal or at/distal to clinoid segment), and near-occlusion. Occlusion etiology and suitability for recanalization were analyzed both on preoperative DSA and HR-VWI. Accuracy of occlusion classification and differences in the modified Rankin scale scores between the baseline and follow-up were estimated. A total of 20 patients were included. With intraoperative DSA as the gold standard, we found HR-VWI could additionally show intraluminal thrombi. Preoperative DSA misclassified one near-occlusion, one type I occlusion, and one type II occlusion as type III occlusions, and one near-occlusion as a type II occlusion. Therefore, compared with the preoperative DSA, three additional cases were successfully recanalized based on HR-VWI. The accuracy of HR-VWI was higher than preoperative DSA (100% vs. 80%). Prognosis improvement of type I was significantly better than type II and near-occlusion (P<0.05). HR-VWI can identify occluded etiology, extent, and classification of CICAO. This information is potentially useful in screening candidates for endovascular recanalization and helpful to indicate prognosis.

Indocyanine Green Administration May Cause an Exaggerated Peripheral Oxygen Desaturation in the Presence of Liver Disease—An Underemphasized Observation

Microscope-integrated indocyanine green video angiography (ICG-VA) is used to assess the completeness of clipping and cerebral vascular flow during aneurysm surgery.[1] It is a more practical and less time-consuming alternative to intraoperative digital subtraction angiography (DSA). ICG has been reported to cause a decrease in peripheral oxygen saturation (SpO2).[2] [3] [4]

Strategies for Treatment of Multiple Brain Aneurysms Without Intraoperative Adjuncts

Although fairly rare, multiple brain aneurysms are well known to occur in certain conditions such as arteriovenous malformations, coarctation of the aorta, renal artery stenosis, adult type 3 polycystic kidney disease, as well as connective tissue disorders (such as Ehlers-Danlos syndrome, Marfan syndrome, and fibromuscular dysplasia). Increased incidence of complications of surgery in such situations is expected to be more likely than in surgery for a single aneurysm, particularly in the absence of intraoperative guidance with adjuncts. We report a case of an anterior communicating artery aneurysm, a right middle cerebral artery aneurysm, and a right pericallosal aneurysm in a 70-year-old man. All 3 aneurysms were clipped through a single-stage approach without the aid of any adjuncts such as micro-Doppler ultrasonography, indocyanine green videoangiography, or intraoperative digital subtraction angiography. We carried out a literature review for past publications on similar reports. The patient made a complete postoperative recovery and sustained no neurologic deficits. Out of 388 publications from the literature search, only 1 case report described clipping of 2 tandem aneurysms in a 60-year-old woman without mentioning any intraoperative adjuncts. This case illustrates that multiple aneurysms can actually be safely operated with adequate planning in the absence of these adjuncts, especially in resource-poor regions. This is particularly crucial in Africa and most low-and-middle-income countries, where such facilities and equipment are not common.

Intraoperative Monitoring Cerebral Blood Flow During the Treatment of Brain Arteriovenous Malformations in Hybrid Operating Room by Laser Speckle Contrast Imaging.

BackgroundHemodynamic changes caused by hybrid surgery for brain arteriovenous malformations (bAVM) are usually related to long-term lesions from “blood stealing”. There are currently no viable low-cost, noninvasive procedures for assessing cerebral perfusion in the operating room. This study aims to investigate the use of intraoperative laser speckle contrast image (LSCI) software in AVM surgery.MethodsIn Zhongnan Hospital of Wuhan University, 14 patients who underwent surgery with LSCI were collected. To analyze the hemodynamic features of AVM and the influence on the peripheral cortex of AVM embolization and resection, we assessed the transit time between feeding arteries and drainage veins by intraoperative digital subtraction angiography (DSA). Meanwhile, LSCI was performed at pre-embolization, post-embolization, and after complete resection of bAVM.ResultsIn this study, the transit time of bAVM before and after embolization was compared, the transit time before embolization was significantly shorter than that after embolization (p < 0.05). We also got good visualization of relative CBF, in addition, to flow imaging in the cortical vasculature round bAVM with LSCI. The flux of post-surgery was significantly higher than pre-embolization (p < 0.01).ConclusionHemodynamic variable assessment plays an important role in the resection of AVM in the hybrid operative room and LSCI can be used to visualize and evaluate cortical cerebral blood flow to detect pathological hyperperfusion in real-time with a good spatial-temporal resolution in a sensitive and continuous, non-invasive mode.

A Weakly Supervised Framework for 2D/3D Vascular Registration Oriented to Incomplete 2D Blood Vessels

Registering preoperative 3D computed tomography (CT) to intraoperative 2D digital subtraction angiography (DSA) can complete the missing part of 2D vessels by 3D-2D projection, which is useful for the guidance of vascular interventional surgery. However, vessel excalation in DSAs remains hard for registration in clinical circumstances. To overcome this challenge, we proposed a weakly supervised 2D/3D vascular registration framework to improve the performance on DSAs with incomplete vessels. We combined a CNN regressor with a novel 3D-2D mask projection module to build the full network. Then a two-step training procedure is employed, including supervised pre-training on simulated images and weakly supervised finetuning on DSAs. In addition, a patch-based content loss is introduced in the finetuning step to give an appropriate similarity measure for images with incomplete vessels. We evaluated our method on both simulated and real images. Experiments prove that our proposed method is effective to improve the backbone regressor’s registration performance on incomplete vessels and has the ability to complete vessels in DSAs with high recall.

Comparison between Digital Subtraction Angiography and Indocyanine Green Video Angiography in the Operative Management of Aneurysmal Subarachnoid Hemorrhage

Abstract Background Digital subtraction angiography (DSA) is a fluoroscopy technique used in interventional radiology to clearly visualize blood vessels in a bony or dense soft tissue environment. Images are produced using contrast medium by subtracting a “pre-contrast image” or mask from subsequent images, once the contrast medium has been introduced into a structure, hence the term “Digital subtraction angiography.” Indocyanine green video angiography (ICG-VA) is a safe and practical method of real-time delineation of microvasculature used in the surgical management of intracranial aneurysms, arteriovenous malformations, and other vascular lesions. Intraoperative ICG-VA is used as an adjunct in addition to intraoperative or postoperative DSA, and in other cases, it is used as the sole method to confirm the complete obliteration of clipped intracranial aneurysm. The only limitation of ICG-VA is the nonvisibility of vessels that are not in the operative field. Intraoperative ICG is useful in the clipping of intracranial aneurysms to ensure a gross patency of branch vessels; however, the presence of residual aneurysms and subtle changes in flow in branch vessels is best seen by DSA. Methods ICG angiography was done during the surgery and the findings of intraoperative ICG angiography were compared with postoperative DSA that was done between 6 and 12 weeks. DSA was done to see any compromise of lumen of parent vessel by clip, any residual aneurysm. Results In our study, intraoperative ICG complete aneurysm obliteration was present in all 30 (100%) patients, while in postoperative DSA complete aneurysm obliteration was diagnosed in 27 (90.0%) patients. Parent vessel patency was present in all 30 (100.0%) patients in both intraoperative ICG-VA and postoperative DSA. In intraoperative ICG distal branch patency was present in 26 (86.7%) patients, while in postoperative DSA distal branch patency was diagnosed in 27 (90.0%) patients. Conclusion We compared the intraoperative ICG finding and postoperative DSA finding and found that DSA is more sensitive than ICG in depicting residual aneurysm neck, hence reducing the risk of rupture of the aneurysm in future. Intraoperative ICG has high special resolution reflex feedback, intraoperative repositioning time is less and thus critical ischemia time is reduced. In a developing country like ours where DSA facilities are limited, ICG can be optimal investigation to delineate the vascular anatomy and confirmation of clip position thus reducing mortality.

High-Resolution Vessel Wall MR Imaging in Diagnosis and Length Measurement of Cerebral Arterial Thrombosis: A Feasibility Study.

Detecting and measuring intraluminal thrombus has prognostic and therapeutic implications for stroke patients. To investigate the feasibility of 3D isotropic high-resolution T1w-CUBE imaging to detect and measure intraluminal thrombus in stroke patients. Retrospective. A total of 93 patients with acute (N=39) and subacute (N= 54) stroke. A 3.0 T/spin-echo echo-planar diffusion-weighted imaging (DWI), high-resolution T1w-CUBE imaging and 3D flow compensated gradient-echo susceptibility-weighted imaging (SWI). Data assessment was performed by three neuroradiologists with 11, 13, and 20 years of clinical experience. The accuracy of T1W-CUBE and SWI in diagnosing thrombosis was compared by using digital subtraction angiography (DSA) as the reference. For thrombus length measurement, the image quality of proximal and distal thrombus of T1w-CUBE images was first evaluated with a 4-point rating system. Then, the proximal and distal positions to lesions were determined on T1w-CUBE images and compared with those from DSA acquired during endovascular reperfusion therapy. If comparable both locations were found between CUBE and DSA, CUBE imaging can thus be considered for accurate measurement of thrombus length. Fleiss' Kappa; the area under the receiver operating characteristic (ROC) curve (AUC); Pearson's chi-squared test with Yates' continuity correction. Moderate-to-good interobserver agreements were validated with all Kappa coefficients higher than 0.40 in thrombus diagnosis and measurement. CUBE imaging showed higher clinical efficacy than SWI (AUC: 0.966 vs. 0.850) in thrombus diagnosis. Additionally, high quality of CUBE imaging was confirmed with 3 or 4 points rated by all three observers. Compared to intraoperative DSA, T1w CUBE showed consistent proximal and distal positions of thrombi in 16 of the 18 patients, validating the accuracy of T1w-CUBE in measuring thrombus length. T1w-CUBE imaging has potential to facilitate diagnosis and measurement of intraluminal thrombus. 4 TECHNICAL EFFICACY: Stage 2.

Thoracic Endovascular Aortic Repair Using the C-TAG® Device with ACTIVE CONTROL System.

To describe our experience with the Gore® C-TAG® endograft with ACTIVE CONTROL System (ACS) (W.L. Gore & Associates, Inc., Flagstaff, AZ, USA) in thoracic aortic repair, focusing on deployment accuracy and aortic wall apposition. All patients who underwent thoracic endovascular aortic repair (TEVAR) using the Gore® C-TAG® endograft with ACS from September 2017 to September 2021 were enrolled in a dedicated database and retrospectively analysed. We collected anatomic data on aortic arch angulation and tortuosity, proximal and distal landing zones, and the target for deployment accuracy. Proximal and distal deployment accuracies (PDA and DDA) were measured through intraoperative digital subtraction angiography (DSA), and postoperative computed tomography angiography (CTA) was required to define endograft apposition to the aortic wall. Twenty-eight patients who underwent TEVAR with the Gore® C-TAG® with ACS at our institution were selected for this study: 46% presented with a type 3 aortic arch and a proximal landing zone < 3 was used in 53% of cases. Mean PDA and DDA were 1.89 ± 3.5 mm and 0.6 ± 1.4 mm, and were obtained in 93% and 100% of procedures, respectively. Mean proximal and distal wall apposition were 91 ± 17% and 98 ± 5.9%. Fifteen patients required an associated planned procedure, either to revascularize supra-aortic vessels when PLZ was < 3 or to assure optimal distal fixation with EndoAnchors™ (Medtronic, Minneapolis, MN, USA) delivery in selected cases. Two patients required reintervention during the same hospitalisation because of type 1a endoleak onset. No further reinterventions were needed during follow-up. Our single-centre analysis found promising results using the Gore® C-TAG® with ACS, with an optimal accuracy in deployment and wall apposition at both proximal and distal landing zones.

Comparison of Endovascular Embolization Plus Simultaneous Microsurgical Resection vs. Primary Microsurgical Resection for High-Grade Brain Arteriovenous Malformations.

Aim: It remains a challenge in surgical treatments of brain arteriovenous malformations (AVMs) in Spetzler-Martin Grade (SMG) IV and V to achieve both optimal neurological outcomes and complete obliteration. The authors reported a series of patients with AVMs in SMG IV and V who underwent a surgical paradigm of endovascular embolization and simultaneous microsurgical resection based on the one-staged hybrid operation.Methods: Participants in the multicenter prospective clinical trial (NCT 03774017) between January 2016 and December 2019 were enrolled. Patients who received endovascular embolization plus microsurgical resection (EE+MRS) and those who received intraoperative digital subtraction angiography plus microsurgical resection (iDSA+MRS) were divided into two groups. Information on clinical features, operative details, and clinical outcomes were extracted from the database. Deterioration of neurological deficits (DNDs) was defined as the primary outcome, which represented neurological outcomes. The time of microsurgical operation and blood loss were defined as the secondary outcomes representing microsurgical risks and difficulties. Outcomes and technical details were compared between groups.Results: Thirty-eight cases (male: female = 23:15) were enrolled, with 24 cases in the EE+MRS group and 14 in the iDSA+MRS group. Five cases (13.2%) were in SMG V and 33 cases (86.8%) were in SMG IV. Fourteen cases (36.8%) underwent the paradigm of microsurgical resection plus intraoperative DSA. Twenty-four cases (63.2%, n = 24) underwent the paradigm of endovascular embolization plus simultaneous microsurgical resection. Degradations of SMG were achieved in 15 cases. Of the cases, two cases got the residual nidus detected via intraoperative DSA and resected. Deterioration of neurological deficits occurred in 23.7% of cases (n = 9) when discharged, and in 13.5, 13.5, 8.1% of cases at the follow-ups of 3, 6, and 12 months, respectively, without significant difference between groups (P > 0.05). Intracranial hemorrhagic complications were reported in three cases (7.9%) of the EE+MRS group only. The embolization did not significantly affect the surgical time and intraoperative blood loss. The subtotal embolization or the degradation of size by 2 points resulted in no DNDs.Conclusions: The paradigms based on the one-staged hybrid operation were practical and effective in treating high-grade AVMs. Appropriate intraoperative embolization could help decrease operative risks and difficulties and improve neurological outcomes.

Intraoperative Spinal Angiography during Microsurgical Occlusion of Spinal Dural Arteriovenous Fistula within the Hybrid Operation Room.

Spinal dural arteriovenous fistula (SDAVF) is a rare cause of progressive myelopathy in predominantly middle-aged men. Treatment modalities include surgical obliteration and endovascular embolization. In surgically treated cases, failure of obliteration is reported in up to 5%. The aim of this technical note is to present a safe procedure with complete SDAVF occlusion, verified by intraoperative digital subtraction angiography (DSA). We describe four patients with progressive leg weakness who underwent surgical obliteration of SDAVF with spinal intraoperative DSA in the prone position after cannulation of the popliteal artery. All surgeries took place in our hybrid operating room (OR) and were accompanied by electrophysiologic monitoring. Surgeries and cannulation of the popliteal artery were performed in the prone position. Ultrasound was used to guide the popliteal artery puncture. A 5-Fr sheath was inserted and the fistula was displayed using a 5-Fr spinal catheter. Spinal intraoperative DSA was performed prior to and after temporary clipping of the fistula point as well after the final SDAVF occlusion. The main feeder of the SDAVF fistula in the first patient arose from the right T11 segmental artery, which also supplied the artery of Adamkiewicz. The second patient initially underwent endovascular treatment and deteriorated 5 months later due to recanalization of the SDAVF via a small branch of the T12 segmental artery. The third and fourth cases were primarily scheduled for surgical occlusion. Access through the popliteal artery for spinal intraoperative DSA proved to be beneficial and safe in the hybrid OR setting, allowing the sheath to be left in place during the procedure. During exposure and after temporary and permanent occlusion of the fistulous point, intraoperative indocyanine green (ICG) video angiography was also performed. In one case, the addition of intraoperative DSA showed failure of fistula occlusion, which was not visible with ICG angiography, leading to repositioning of the clip. Complete fistula occlusion was documented in all cases. Spinal intraoperative DSA in the prone position is a feasible and safe intervention for rapid localization and confirmation of surgical SDAVF occlusion.