Use Of Intraoperative Angiography Research Articles

Mid-term Outcomes of Image-Guided Surgical Thromboembolectomy and Routine Intraoperative Angiography for Native Vessel Acute Lower-Limb-Threatening Ischemia.

Standard balloon-catheter thromboembolectomy (TE) is an established effective treatment for acute lower-limb ischemia (ALI) with recognized limitations when there is an underlying arterial lesion or thromboembolism of the infrapopliteal arteries. The aim of this study was to evaluate the efficacy and safety of image-guided surgical TE combined with routine intraoperative completion angiography in the treatment of ALI patients. Between September 2020 and August 2022, this prospective study included all consecutive adult patients presenting to a tertiary center with unilateral ALI of Rutherford class II due to thromboembolic occlusion of native arteries who underwent image-guided surgical TE and routine completion intraoperative angiography. Adjunctive endovascular techniques (hybrid revascularization) including plain balloon angioplasty (PTA)±stenting or on-table lysis were used if underlying arterial lesions or residual thrombosis were detected on the intraoperative angiography, respectively. The primary outcome measures included technical success and 30-day major amputation rate. Perioperative complications, 1-year primary and secondary patency, limb salvage, mortality, and amputation-free survival rates were endorsed as secondary outcome measures. Image-guided surgical thrombectomy was done for 109 ALI patients (109 limbs), provisionally diagnosed as embolic (57 patients, 52.3%) or thrombotic (52 patients, 47.7%) arterial occlusion. Thromboembolectomy without adjunctive endovascular treatment was done in 38 patients (34.86%), whereas 71 patients (65.14%) required adjunctive PTA±stenting of underlying arterial lesions (60, 55.05%) or on-table lysis±PTA of residual thrombosis (11, 10.09%). The overall technical success rate was 92.66%. At 30 days, amputation and mortality rates were 3.67% and 5.5%, respectively. None of the patients had thrombectomy-induced arterial injuries. One-year follow-up data were available for 81 patients (74.3%). The Kaplan-Meier estimate of the 12-month primary and secondary patency, limb salvage, and amputation-free survival rates was 76.5%±0.04, 91.5%±0.03, 90.6±0.03, and 91.4±0.03%, respectively. Image-guided TE combined with routine intraoperative angiography is a safe and effective technique for surgical TE in acute lower-limb ischemia patients with the advantage of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. The present study has confirmed the safety and effectiveness of image-guided thromboembolectomy combined with routine use of intraoperative angiography during surgical treatment of acute lower limb ischemia in terms of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. This technique also facilitates selective passage of Fogarty balloon catheter into infrapopliteal arteries from the femoral approach which is traditionally done by exploration of the popliteal trifurcation or tibial arteries under regional or general anesthesia. Using this technique can guide the operating surgeon for adequate balloon manipulation and inflation to avoid iatrogenic vessel injury.

Does the Use of Intraoperative Angiography Reduce the Incidence of Postoperative Wound and Flap Complications in Complex Lower Extremity Oncologic Reconstruction?

Intraoperative laser angiography via indocyanine green (ICG) has become a valuable tool in objectively assessing tissue perfusion in reconstructive procedures. Studies have demonstrated the utility of ICG angiography (ICGA) for decreasing both mastectomy skin flap necrosis and wound healing complications in abdominal wall reconstruction. This tool has not been studied in lower extremity oncologic reconstruction. The objective of this study was to compare postoperative complications in lower extremity oncologic reconstruction managed with or without laser-assisted ICGA. A retrospective chart review was performed of patients undergoing complex lower extremity oncologic reconstruction at a single institution between 2000 and 2018. Patient information regarding demographics, comorbidities, operative procedures, and postoperative complications was analyzed. Sixty-one patients were identified in our study. As some patients underwent multiple reconstructive surgeries, a total of 76 reconstructive procedures were analyzed. Patients with plastic surgery reconstruction using ICGA (n = 36) were compared with those without, non-ICGA (n = 40). No significant differences in age, sex, smoking status, chemotherapy, or radiation history were identified between cohorts. The total number of postoperative complications did not statistically differ between cohorts. There was no statistically significant difference in the number of required reoperation because of a postoperative complication between the ICGA and non-ICGA groups (0.44 vs 0.4). The incidence of postoperative wound complications after complex lower extremity oncologic reconstruction remains high. The findings of our study suggest that clinical judgment of flap and soft tissue viability, as compared with ICGA, may lead to comparable operative outcomes and be more cost-effective. Long-term follow-up and prospective studies are needed to further investigate this trend.

Two-Stage, Prepectoral Breast Reconstruction: Standardized Technique and Outcomes Analysis During First Stage to Reduce Complications and Ensure Reliability.

Prepectoral breast reconstruction is seeing a resurgence in popularity as advances in breast oncology and breast reconstruction continue to occur. This study seeks to describe a simple, reproducible method for prepectoral breast reconstruction and analyzes patient demographics and outcomes after the first stage of prepectoral breast reconstruction. After institutional review board approval was obtained, a retrospective chart review was performed to identify patients who underwent 2-stage prepectoral reconstruction by the senior author from January 2019 to February 2020. Patient demographics including body mass index, nicotine use, diabetes mellitus, neoadjuvant chemotherapy, and adjuvant radiation were analyzed. Type of mastectomy (nipple vs skin sparing), unilateral versus bilateral reconstruction, and use of intraoperative angiography were also assessed. Complications including excision of ischemic skin, delayed mastectomy flap ischemia, seroma, hematoma, axillary cellulitis, expander infection, and reconstructive failure were analyzed. χ2 Analysis was used to identify any association between the above demographics and infection, and P values were generated with a statistical significance being denoted by a P < 0.05. One hundred five breast reconstructions were included in this study. A statistically significant association was found between nicotine use, diabetes mellitus, excision of ischemic skin, and expander infection. No significant association was found between other demographics and infection risk. Expander infection occurred in 2.86% of all reconstructions with an overall reconstructive failure rate of 2.86%. This study demonstrates that our technique is reproducible and can be used for all types of mastectomies and incisions. Our data analysis demonstrates that this is a reliable method of breast reconstruction if performed correctly in the properly selected patient. Future studies will assess outcomes following the second stage of reconstruction.

腹腔動脈狭窄症例に対する膵頭十二指腸切除術にハイブリッド手術室での術中血管造影が有用であった2例の経験

症例1は77歳の男性で，黄疸の精査にて遠位胆管癌と診断された．症例2は57歳の男性で，貧血の精査にて内視鏡的切除が困難な十二指腸腫瘍と診断された．2例とも腹部ダイナミックCTにて腹腔動脈（celiac artery；以下，CAと略記）起始部の狭窄が指摘された．血管造影検査でも特に吸気時でCA狭窄が強く認められ，肝動脈血流は，上腸間膜動脈からの膵頭部アーケードを経由して得られていた．いずれも正中弓状靭帯による圧迫が狭窄の原因と考えられ，手術では靭帯切離，狭窄解除を行った．術中大動脈造影にてCAの血流の正常化が確認できたため，血行再建を行わずに膵頭十二指腸切除を施行した．一般的には，正中弓状靱帯切離前後の血流評価は触診や超音波ドプラ法によって行われることが多い．今回，我々はハイブリッド手術室にて術中血管造影を行うことでCA血流の改善を従来の方法と比べて視覚的に評価することができた．

Comparing routine versus selective use of intraoperative cerebral angiography in aneurysm surgery: a prospective study

IntroductionWhile the use of intraoperative angiography (IA) has been shown to be a useful adjunct in aneurysm surgery, its routine use remains controversial.ObjectiveWe wished to determine if IA is required...

Advances in Surgical Approaches to Dural Fistulas

Dural arteriovenous fistulas are abnormal connections of dural arteries to dural veins or venous sinuses originating from within the dural leaflets. They are usually located near or within the wall of a dural venous sinus that is frequently obstructed or stenosed. The dural fistula sac is contained within the dural leaflets, and drainage can be via a dural sinus or retrograde through cortical veins (leptomeningeal drainage). Dural arteriovenous fistulas can occur at any dural sinus but are found most frequently at the cavernous or transverse sinus. Leptomeningeal venous drainage can lead to venous hypertension and intracranial hemorrhage. The various treatment options include transarterial and transvenous embolization, stereotactic radiosurgery, and open surgery. Although many of the advances in dural arteriovenous fistula treatment have occurred in the endovascular arena, open microsurgical advances in the past decade have primarily been in the tools available to the surgeon. Improvements in microsurgical and skull base approaches have allowed surgeons to approach and obliterate fistulas with little or no retraction of the brain. Image-guided systems have also allowed better localization and more efficient approaches. A better understanding of the need to simply obliterate the venous drainage at the site of the fistula has eliminated the riskier resections of the past. Finally, the use of intraoperative angiography or indocyanine green videoangiography confirms the complete disconnection of fistula while the patient is still on the operating room table, preventing reoperation for residual fistulas.

Safety and Efficacy of Intraoperative Angiography in Craniotomies for Cerebral Aneurysms and Arteriovenous Malformations

In an era of indocyanine angiography, the routine use of intraoperative angiography (IOA) in the surgical treatment of aneurysms and vascular malformations is controversial. To retrospectively assess the safety and efficacy of IOA and to determine predictors of surgical revision. Between 2003 and 2011, IOA was performed during surgical treatment of 976 aneurysms, 101 arteriovenous malformations (AVMs), and 16 arteriovenous fistulas. In 80 of 976 aneurysms (8.2%), IOA prompted clip repositioning. The reason for readjustment was residual aneurysm in 54.7%, parent vessel occlusion in 42.9%, and both in 2.4% of cases. In multivariate analysis, increasing aneurysm size (P, .001), ruptured aneurysm (P, .001), and increasing number of vessels injected (P, .001) were strong predictors of clip readjustment. There was a strong trend for posterior circulation aneurysm location to predict clip repositioning (P = .06). IOA revealed residual nidus/ fistula requiring further intervention in 9 of 101 AVMs (8.9%) and 3 of 16 arteriovenous fistulas (18.8%). Of 9 AVMs requiring a surgical revision, 2 (22.2%) were Spetzler-Martin grade II, 5 (55.6%) were grade III, and 2 (22.2%) were grade IV. Mean Spetzler-Martin grade was 3.0 in AVMs requiring surgical revision compared with 2.3 in those not requiring revision (P = .05). IOA-related complications were all transient or minor and occurred in 0.99% of patients; none resulted in permanent morbidity. IOA remains a valuable tool in the surgical treatment of brain vascular abnormalities, guiding surgical re-exploration in .8% of cases. Easy access to an angiographer and routine use of IOA are important factors contributing to procedural safety and efficacy.

Does Routine Completion Angiogram During Embolectomy for Acute Upper-Limb Ischemia Improve Outcomes?

Since 1963, Fogarty balloon catheter thromboembolectomy is usually adopted as the gold standard treatment for acute limb ischemia. As the success of the procedure depends on complete removal of all thromboembolic material, intraoperative arteriography can be used after arterial thromboembolectomy as a guide for extension of the procedure. It is still a matter of debate whether intraoperative angiography should be routinely performed in all cases or only in selected cases, depending on intraoperative findings, when the surgeon suspects an incomplete disobstruction. Most published evidence derives from analysis of lower-limb thromboembolectomies. The aim of our retrospective study was to elucidate the value of routine completion angiogram in acute arterial embolism of the upper limb. Clinical and demographic data of 100 patients with acute embolic upper-limb ischemia were prospectively recorded during an 18-year period in a central hospital vascular unit setting. The relevance of intraoperative angiography was retrospectively analyzed. The procedures were divided into two groups: group A, when intraoperative angiography was performed in selected cases (selective angiography); and group B, when angiography was performed as a routine procedure in all cases (routine angiography). All factors associated with reocclusion and mortality were investigated to produce meaningful information that could assist the surgeon to predict outcomes. Cumulative reocclusion and mortality rates at 24 months were 14.0% and 70.0%, respectively. After upper-limb arterial embolectomy, the rate of extension of the procedure was significantly higher in group B than in group A (26.0% vs. 4.0%, P = 0.002). At 24 months after embolectomy, group B resulted in a lower incidence of reocclusion compared with group A (12.0% vs. 2.0%, P = 0.05), whereas there was no statistical difference between the two groups in terms of mortality (P > 0.05). On univariate analysis, the factor associated with increased 2-year reocclusion rate was only the avoidance of completion angiography, although it lost some of its predictive value on multivariate analysis. Factors associated with increased 2-year mortality rate on univariate analysis included age >80 years, diabetes mellitus [DM], and antiplatelet drug use. Only DM was significantly associated on multivariate analysis. Routine use of intraoperative angiography influences outcome after embolectomy for upper-limb acute arterial occlusion. Routine use of intraoperative angiography, compared with selective use, results in a higher rate of extension of the procedure for residual lesion and in a lower rate of reocclusion at 24 months. In prevention of reocclusion, completion angiogram has a hazard ratio of 5.44 on multivariate analysis. Postoperative late mortality is mainly affected by old age and DM.

Routine Versus Selective Use of Intraoperative Angiography During Thromboembolectomy for Acute Lower Limb Ischemia: Analysis of Outcomes

The success of thromboembolectomy for acute lower limb ischemia depends on the complete removal of all thromboembolic material accessible to the Fogarty catheter. Intraoperative arteriography can be used during arterial thromboembolectomy as a guide for extension of procedure to ensure complete clearance of the arterial tree and distal patency. However, it is still matter of debate if intraoperative angiography should be routinely performed in all cases or only in selected cases, depending on intraoperative findings, when the surgeon suspects an incomplete desobstruction. Details of 380 thromboembolectomies in 361 patients with acute lower limb ischemia due to native vessel occlusion were prospectively recorded over a 12-year period in a central hospital vascular unit setting. The relevance of intraoperative angiography was retrospectively analyzed. The procedures were divided into two groups: group A, when intraoperative angiography was performed in selected cases (selective angiography), and group B, when angiography was performed as a routine procedure in all cases (routine angiography). Thrombectomy and embolectomy cases were separately analyzed. "On-table" angiography was used in 57 (26.4%) of 216 cases in group A and in all 164 cases (100%) of group B. Included in this study were 225 embolectomies and 155 thrombectomies of native vessels. After thrombectomy, the adoption of routine intraoperative angiography (group B) resulted in a statistically significant higher intraoperative reintervention rate than did selective intraoperative angiography (group A) (53.4% vs. 29.9%; p < 0.05). Also, after embolectomy extension of procedure, the rate was higher in group B than in group A (17% vs. 9.2%), but it did not reach statistical significance (p > 0.05). Considering the overall casuistic, at 24 months after thromboembolectomy, group B resulted in a lower incidence of reocclusion in comparison with group A (p < 0.05), whereas there was no statistical difference between the two groups in terms of amputation (p > 0.05) or of mortality (p > 0.05). Considering separately patients treated by embolectomy and by thrombectomy, reocclusion rate at 24 months was lower in group B than in group A, after thrombectomy and after embolectomy, with a statistical significance (p < 0.05). Amputation rate at 24 months was similar in group A and group B after embolectomy (10.7% vs. 8.9%; p > 0.05). After thrombectomy, there was in group B a slight advantage in comparison with group A, although not reaching statistical significance (31.3% vs. 46.2%; p > 0.05). There was no difference in mortality rate according to treatment group. Routine use of intraoperative angiography influences outcome after thromboembolectomy for lower limb acute arterial occlusion. Routine use of intraoperative angiography, compared with selective use, results in higher rate of extension of the procedure for residual lesion and in a lower reocclusion rate at 24 months.

Intraoperative angiography in aneurysm surgery: An initial experience

Intraoperative angiography (IOA) assumes an important role in the prevention of complications such as aneurysmal neck remnant or compromise of adjacent cerebral vasculature during surgery for cerebral aneurysms. Aims : To determine the feasibility, efficacy and safety of IOA in aneurysmal surgery. Prospective study of IOA in patients undergoing aneurysmal surgery. IOA was performed using digital subtraction angiography (DSA) compatible C-arm, radiolucent operating table and appropriate femoral sheath, guiding catheters and guide wires in 20 consecutive patients after surgical clipping of the cerebral aneurysm. The post-clipping IOA was compared with preoperative angiogram. Complete aneurysmal obliteration was confirmed in all the patients. In two patients compromization of adjacent vessels was noted, which could be rectified by repositioning of the clip. Some degree of vasospasm was noted in all the patients. Intra-arterial nimodipine was administered in four patients with severe vasospasm. There was improvement in two patients. Time taken for performing IOA varied from 30 to 45 min. No complications attributable to IOA were encountered in this study. IOA is a safe and effective adjunctive tool for aneurysm clipping. Routine use of IOA in all cases of aneurysmal surgery is recommended.

Intraoperative Angiography during Cerebral Aneurysm Surgery

Intraoperative angiography (IOA) has been considered since the 1960s for use during surgical repair of cerebral aneurysms. The potential of IOA to confirm complete aneurysm occlusion and patency of the parent vasculature intraoperatively are of significant clinical value. Over the past 5 to 7 years, use of intraoperative angiography has been increasing, and many centres now use the technique frequently. However, no consensus exists regarding the routine use of IOA in cerebral aneurysm surgery. Different institutional paradigms include the use of IOA rarely or never, selectively based on aneurysm complexity, or routinely in all aneurysm cases. This article describes the authors’ use of intraoperative angiography with particular emphasis on practical recommendations for implementing an institutional program of routine IOA as an adjunct to all surgeries for aneurysm repair. Recent improvements in radiolucent headholders and retractors, as well as improved digital subtraction angiography using portable fluoroscopy units have enabled the more efficient and practical use of intraoperative angiography. Traditionally, successful aneurysm clipping has been confirmed intraoperatively by inspection of the aneurysm clip and adjacent vasculature, combined with aneurysm puncture to confirm occlusion, prior to the closure of the craniotomy. Intraoperative angiography had historically been reserved for the most complex cases. Between 5.1 and 7.3% of surgically treated aneurysms are unexpectedly incompletely occluded, leading to additional treatment or ongoing risk of rupture [1–5]. Without IOA, the surgeon’s only means to confirm complete aneurysm occlusion is to puncture the aneurysm dome. This is not necessary after ruling out residual filling of clipped aneurysm through intraoperative angiography. An incompletely occluded aneurysm will hemorrhage from the puncture site, which although not usually problematic, is certainly not an optimal means to discover incomplete aneurysm occlusion. Parent vessel occlusion during surgical clipping of a cerebral aneurysm occurs in approximately 3–14% of cases [1–6]. Although rare, parent vessel occlusion can lead to permanent neurological deficit or death. Furthermore, only a small window of time exists to recognize parent vessel occlusion and restore flow before irreversible ischemia of brain parenchyma occurs, and therefore, postoperative investigations demonstrating parent vessel occlusion do not generally lead to successful intervention. IOA can demonstrate parent vessel occlusion in a timely manner, and lead to corrective intervention during the initial craniotomy. Furthermore, IOA alters the aggressiveness required in confirmation of anatomy and inspection of the distal tips of the aneurysm clip. Although rare, complications related to aggressive clip inspection do occur, and can be mitigated by IOA in certain cases. Others studies of cerebral blood flow such as microdoppler auscultation and postoperative R. Kumar J. A. Friedman (&) Department of Surgery, Texas A&M Health Science Center College of Medicine, 3201 University Drive, Suite 425, Bryan-College Station, TX 77802, USA e-mail: jafriedman@medicine.tamhsc.edu

Intraoperative angiography should be standard in cerebral aneurysm surgery

Intraoperative angiography (IOA) has proven to be a safe and effective adjunct to surgical repair of cerebral aneurysms. Substantial practice variation exists regarding use of this modality in different centers, including use of IOA routinely, selectively, or rarely. In this editorial, we discuss our experience and review the existing literature to develop an argument for routine use of IOA during cerebral aneurysm surgery.

Clipping of very large or giant unruptured intracranial aneurysms in the anterior circulation: an outcome study

Patients with very large or giant unruptured intracranial aneurysms present with ischemic stroke and progressive disability. The aneurysm rupture risk in these patients is extreme-up to 50% in 5 years. In this study the authors investigated the outcome of surgical treatment for these very large aneurysms in the anterior circulation. METHODS Clinical data on 62 patients who underwent surgery for unruptured aneurysms (20-60 mm) between 1998 and 2006 were reviewed. Complete aneurysm occlusion (100%) was achieved in 90% of cases, near complete occlusion (90-99%) in 5%. The surgical risk in patients younger than 50 years of age was 8% (Glasgow Outcome Scale score of 1 or 3 within 1 year after surgery). In older patients, the risk increased with advancing age. The treatment of very large or giant unruptured intracranial aneurysms is hazardous and complex and thus best performed only at major cerebrovascular centers with an experienced team of neurosurgeons, interventional neuroradiologists, neurologists, and neuroanesthesiologists. Surgery, with acceptable risks and excellent occlusion rates, is typically the treatment of choice in patients younger than 50 years of age. In older patients, the benefits of endovascular treatment versus surgery versus no treatment must be carefully weighed individually. Minimizing temporary occlusion and the consequent use of intraoperative angiography may help reduce surgical complications.

CLINICAL USEFULNESS AND SAFETY OF ROUTINE INTRAOPERATIVE ANGIOGRAPHY FOR PATIENTS AND PERSONNEL

The routine use of intraoperative angiography (IA) is still surrounded by controversy. We prospectively performed IAs in consecutive patients undergoing surgery for aneurysms, arteriovenous malformations, and dural arteriovenous fistulae. We calculated the percentage of identified residual pathologies, the cases requiring further surgical intervention, and the complication rates associated with the procedure. We also recorded radiation dose received by personnel during IA for comparison with elective procedures. If our review supported the routine use of IA, recommendations should be tempered by radiation dose to personnel regarding whether or not annual exposure would go beyond recommended limits and whether or not radiation doses indicate a need for specialized operating rooms. Two hundred and four consecutive IAs were performed on 191 patients over a 2-year period. Angiographic findings were reviewed retrospectively and noted for additional interventions. Complications related to IA were recorded. Radiation doses received by personnel and fluoroscopy times were compiled from 18 IAs. Mean dose/minutes in intraoperative procedures was compared with mean dose/minutes of a separate cohort of 15 elective angiograms (Student's t test). Twenty-three percent of IAs revealed relevant findings. Clip repositioning or additional clip placement was performed in 8% of the patients. Resection of residual arteriovenous malformations or additional surgery for residual arteriovenous shunting in dural arteriovenous fistulae was performed in 2% of the patients. Fewer than 1% of the patients received intra-arterial verapamil or topical papaverine. The complication rate was less than 1%. The mean dose per procedure for physicians was 1.018 microsieverts (uSv) versus 0.988 uSv for technicians (P = 0.94). The mean effective dose/minutes in the angiogram suite was 0.9209 uSv/minute versus 1.213 uSv/minute in the operating room (P = 0.33). IA identifies a significant number of pertinent findings during open neurovascular surgery, half of which require additional intervention. It is associated with a low complication rate. Radiation dose received by personnel per procedure is negligible. IA radiation dose is not different from dose in the angiogram suite; thus, specialized operating rooms may not be necessary. These data support routine intraoperative angiography in open surgeries for neurovascular disorders.

The Eighth Pediatric Interventional Cardiac Symposium (PICS-VIII) and Second Emerging New Technologies in Congenital Heart Surgery (ENTICHS-II)

In this issue, a second set of review articles written by notables in the field of pediatric interventional cardiology is presented. These topics were discussed during the PICS and ENTICHS–2004 held in Chicago. As we mentioned in the previous review issue, 700 professional from more than 50 countries attended this symposium. Many live cases were performed and transmitted live via satellites from 10 cardiac centers in Europe and the United States during this meeting. In addition, there were many lectures given by the course-distinguished faculty. In this review issue of Pediatric Cardiology, 11 papers are presented. These were written by the PICS–2004 speakers. The first two papers discuss catheter closure of ventricular septal defects. Dr. Masura discusses the perimembranous ventricular septal defects, and Dr, Thanopoulos discusses muscular ventricular septal defects. This is followed by Dr. Ewert’s article, which discusses challenges encountered during catheter closure of patent ductus arteriosus. Then, two papers discussing patent foramen ovale (PFO) and new devices are presented; Dr, Morandi and colleagues discuss the association between migraine headaches and PFO, and Dr. Hein and colleagues discuss new devices for PFO and the left atrial appendage. Drs. Kumar and Tynan review the issues and difficulties of performing interventional procedures for congenital heart disease in Third World countries. This is followed by a new area of imaging written by Raval and colleagues for the use of MRI to guide pediatric endovascular procedures. Then, Dr. Ing discusses the topic of stent and delivery to target lesions. Specifically, he discusses the issue of intraoperative stenting and use of intraoperative angiography in collaboration with surge ions. The final two articles discuss embolization techniques; Tan and colleagues review the retrieval of coils and device, and in a review article Dr. Walsh discusses advanced embolization techniques. Finally, Ruiz discusses the latest aspects of transcatheter valve repair/replacement. He focuses on the aortic and mitral valves. We are certain that the two review issues of Pediatric Cardiology will significantly add to our body of knowledge in this continually evolving area of pediatric interventional cardiology. The next PICS/ENTICHS in September 2005 will be held in Buenos Aires, Argentina, immediately preceding the Fourth World Congress of Pediatric Cardiology and Cardiac Surgery.

Selective intraoperative angiography in intracranial aneurysm surgery: intraoperative factors associated with aneurysmal remnants and vessel occlusions

BACKGROUND The objective of this study was to assess the role of selective intraoperative angiography and to analyze the factors associated with faulty clip application. METHODS Two hundred thirty-eight patients undergoing surgery for intracranial aneurysms were studied consecutively for intraoperative angiography (IOA)-related events. The procedure was performed in 155 operations. Demographic details, clinical grade of the patient, location and size of the aneurysm, intraoperative rupture, application of the temporary clip, IOA findings, and final outcome were analyzed. RESULTS In the 155 patients in the series, there were 125 anterior circulation aneurysms and 30 on the vertebrobasilar system. Aneurysms were smaller than 10 mm in 63% of the patients, and 19 were giant aneurysms. Thirty-eight percent were unruptured, 36% were Hunt and Hess Grades I and II, 21% were Grade III, and 5% were Grades IV and V. An intraoperative rupture occurred in 18 operations. Intraoperative angiography was normal in 88%; in 11 cases (7%) there was a residual neck, and in 8 (5%), occlusion of the artery was observed. An incomplete clipping was significantly related to intraoperative rupture of the aneurysm ( p < 0.008) and anterior location of the aneurysm ( p = 0.05), whereas vessel occlusion had a significant association with posterior location of the aneurysm ( p < 0.0005). An eventful IOA had significant association with poor outcome ( p < 0.003). CONCLUSION Intraoperative rupture and a posterior location of the aneurysm had a significant correlation with residual aneurysm and vessel occlusion, respectively. The use of IOA is justified in aneurysms associated with these factors.

Routine intraoperative angiography during aneurysm surgery.

The routine use of intraoperative angiography as an aid in the surgical treatment of aneurysms is uncommon. The advantages of the ability to visualize residual aneurysm or unintended occlusion of parent vessels intraoperatively must be weighed against the complications associated with repeated angiography and prolonged vascular access. The authors reviewed the results of their routine use of intraoperative angiography to determine its safety and efficacy. Prospectively gathered data from all aneurysm cases treated surgically between January 1996 and June 2000 were reviewed. A total of 303 operations were performed in 284 patients with aneurysms; 24 patients also underwent postoperative angiography. Findings on intraoperative angiographic studies prompted reexploration and clip readjustment in 37 (11%) of the 337 aneurysms clipped. Angiography revealed parent vessel occlusion in 10 cases (3%), residual aneurysm in 22 cases (6.5%), and both residual lesion and parent vessel occlusion in five cases (1.5%). When compared with subsequent postoperative imaging, false-negative results were found on two intraoperative angiograms (8.3%) and a false-positive result was found on one (4.2%). Postoperative angiograms obtained in both false-negative cases revealed residual anterior communicating artery aneurysms. Both of these aneurysms also subsequently rebled, requiring reoperation. In the group that underwent intraoperative angiography, in 303 operations eight patients (2.6%) suffered complications, of which only one was neurological. In the surgical treatment of intracranial aneurysms, the use of routine intraoperative angiography is safe and helpful in a significant number of cases, although it does not replace careful intraoperative inspection of the surgical field.

The use of intraoperative angiography in the management of neurovascular disorders

Objective: To review our experience of intraoperative angiography in dealing with neurovascular disorders and to substantiate the usefulness of this investigation.Method: From April 1999 to November 2000, 32 cases of intraoperative angiogram were studied.Results: Two out of 30 intraoperative angiograms were unsuccessful. The angiographic machine broke down during one of the attempts. In one patient, intimal dissection of the femoral artery was noted during the procedure and the study was abandoned; the patient recovered uneventfully. Among the 30 completed angiograms, 19 were for cerebral aneurysm, 10 for arteriovenous malformation (AVM) and one for extracranial–intracranial (EC‐IC) bypass. There was no procedure‐related complication. Among the 19 angiograms performed for cerebral aneurysms, total occlusion was confirmed in 14 patients (74%), residual aneurysms were detected in two patients (10%) and branch occlusions were detected in three patients (16%). Of the 10 angiograms performed for AVM, total removal was confirmed in nine (90%), whereas residual AVM was detected in one patient (10%). One intraoperative angiogram for EC‐IC bypass confirmed the patency of the graft.Conclusions: The study showed that cerebral intraoperative angiography is safe and frequently reveals unclipped aneurysm necks, unexpected major vessel occlusion and residual AVM. Intraoperative cerebral angiography should be recommended as a standard practice for treating neurovascular disorders. Chinese Abstract imageimage

700 Prospective Use of Intraoperative Angiography in 520 Consecutive Cerebral Aneurysms

700 Prospective Use of Intraoperative Angiography in 520 Consecutive Cerebral Aneurysms

Saphenous vein and radial artery grafts in the management of skull base tumors and aneurysms

Cerebral revasularization procedures have had a significant impact in the management of difficult and large cranial base tumors, giant and fusiform aneurysms considered inoperable, and chronic ischemia refractory to maximal medical therapy. Based on our experience with saphenous vein and radial artery graft bypass procedures, we describe the indications, techniques, complications, and pitfalls with their avoidance and our results. Over a period of about 14 years we have operated on 127 patients, with 120 saphenous vein grafting and 12 radial artery grafting procedures being performed. The graft patency rate improved to 98% with the routine use of intraoperative angiography. The surgical mortality rate was 4%, including patients who were in a poor condition at the time of the operation.