Introduction: In an era of indocyanine angiography (ICG), the routine use of intra-operative angiography (IOA) in the surgical treatment of intracranial aneurysms and arteriovenous malformation (AVM) is controversial. We assess the safety and efficacy of IOA and determine predictors of clip readjustment.
Methods: Between 2003 and 2011, IOA was performed during surgical treatment of 976 aneurysms, 97 AVM, and 16 arteriovenous fistulas (AVF) in our institution. A 5-French sheath and Berenstein catheter were used under a portable single-plane fluoroscopy unit. In each case, IOA was performed by the operating neurosurgeon.
Results: A single vessel injection was performed in 876 of 976 aneurysm procedures (89.8%). In 80 of 976 cases (8.2%) IOA prompted clip repositioning. The reason for the readjustment was residual aneurysm in 54.7%, parent vessel occlusion in 42.9%, and both findings in 2.4% of cases. Eight patients (10%) required multiple clip readjustments. In multivariate logistic regression analysis, increasing aneurysm size (p<0.0001), ruptured aneurysm (p=0.001) and increasing number of vessels injected (p=0.001) were strong predictors of clip readjustment. There was a strong trend for posterior circulation aneurysm location to predict clip repositioning (p=0.06). IOA revealed residual nidus/fistula in 8 (8.2%) of 97 AVM and 3 (18.8%) of 16 AVF. In 21.6% of AVM and 56.3% of AVF, more than 1 vessel was injected during IOA. IOA-related complications were all minor and occurred in 10 (0.9%) of 1089 patients (5 retroperitoneal hematomas, 3 groin hematomas, 1 transient limb ischemia, and 1 visual transient ischemic attack); none resulted in permanent morbidity.
Conclusions: IOA is a valuable tool in the surgical treatment of brain vascular abnormalities, guiding surgical re-exploration in over 8% cases. Easy access to portable fluoroscopy and angiographer are important factors contributing to procedural safety and efficacy.
Patient Care: This is the largest study to date to assess the safety and usefulness of IOA during surgical treatment of brain vascular abnormalities. We, hereby, provide important data highlighting the safety and usefulness of IOA which supports its routine use during surgical treatment of brain vascular abnormalities for improved patient outcome.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Discuss the safety and efficacy of IOA during surgical treatment of intracranial aneurysms, AVM, and AVF. 2) Discuss predictors of clip revision for aneurysms and further nidus/fistula resection for AVM and AVF 3) Optimize the treatment of patients undergoing surgical treatment for brain vascular abnormalities.