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

Abstract

Background 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).

Methods 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.

Results 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.

Conclusion Spinal intraoperative DSA in the prone position is a feasible and safe intervention for rapid localization and confirmation of surgical SDAVF occlusion.

Keywords

spinal dural arteriovenous fistula - intraoperative DSA - hybrid operation room

Publication History

Received: 03 January 2021

Accepted: 31 May 2021

Article published online:
20 December 2021

• References

• 1 Saladino A, Atkinson JL, Rabinstein AA. et al. Surgical treatment of spinal dural arteriovenous fistulae: a consecutive series of 154 patients. Neurosurgery 2010; 67 (05) 1350-1357 , discussion 1357–1358
• 2 Jellema K, Canta LR, Tijssen CC, van Rooij WJ, Koudstaal PJ, van Gijn J. Spinal dural arteriovenous fistulas: clinical features in 80 patients. J Neurol Neurosurg Psychiatry 2003; 74 (10) 1438-1440
• 3 Aghakhani N, Parker F, David P, Lasjaunias P, Tadie M. Curable cause of paraplegia: spinal dural arteriovenous fistulae. Stroke 2008; 39 (10) 2756-2759
• 4 Afshar JK, Doppman JL, Oldfield EH. Surgical interruption of intradural draining vein as curative treatment of spinal dural arteriovenous fistulas. J Neurosurg 1995; 82 (02) 196-200
• 5 Sherif C, Gruber A, Bavinzski G. et al. Long-term outcome of a multidisciplinary concept of spinal dural arteriovenous fistulae treatment. Neuroradiology 2008; 50 (01) 67-74
• 6 Andres RH, Barth A, Guzman R. et al. Endovascular and surgical treatment of spinal dural arteriovenous fistulas. Neuroradiology 2008; 50 (10) 869-876
• 7 Kirsch M, Berg-Dammer E, Musahl C, Bäzner H, Kühne D, Henkes H. Endovascular management of spinal dural arteriovenous fistulas in 78 patients. Neuroradiology 2013; 55 (03) 337-343
• 8 Bowen BC, Fraser K, Kochan JP, Pattany PM, Green BA, Quencer RM. Spinal dural arteriovenous fistulas: evaluation with MR angiography. AJNR Am J Neuroradiol 1995; 16 (10) 2029-2043
• 9 Villelli NW, Lewis DM, Leipzig TJ, DeNardo AJ, Payner TD, Kulwin CG. Intraoperative angiography via the popliteal artery: a useful technique for patients in the prone position. J Neurosurg Spine 2018; 29 (03) 322-326
• 10 Orru' E, Sorte DE, Wolinsky JP. et al. Intraoperative spinal digital subtraction angiography: indications, technique, safety, and clinical impact. J Neurointerv Surg 2017; 9 (06) 601-607
• 11 Fandino J, Taussky P, Marbacher S. et al. The concept of a hybrid operating room: applications in cerebrovascular surgery. Acta Neurochir Suppl (Wien) 2013; 115: 113-117
• 12 Sanborn MR, Crowley RW, Uschold T, Park MS, Albuquerque FC, McDougall CG. Spinal dural arteriovenous fistulas: how, when, and why. Neurosurgery 2014; 61 (Suppl. 01) 6-11
• 13 Bakker NA, Uyttenboogaart M, Luijckx GJ. et al. Recurrence rates after surgical or endovascular treatment of spinal dural arteriovenous fistulas: a meta-analysis. Neurosurgery 2015; 77 (01) 137-144 , discussion 144
• 14 Steinmetz MP, Chow MM, Krishnaney AA. et al. Outcome after the treatment of spinal dural arteriovenous fistulae: a contemporary single-institution series and meta-analysis. Neurosurgery 2004; 55 (01) 77-87 , discussion 87–88
• 15 Wang G, Ma G, Ma J. et al. Surgical treatment of spinal vascular malformations performed using intraoperative indocyanine green videoangiography. J Clin Neurosci 2013; 20 (06) 831-836
• 16 Raabe A, Beck J, Gerlach R, Zimmermann M, Seifert V. Near-infrared indocyanine green video angiography: a new method for intraoperative assessment of vascular flow. Neurosurgery 2003; 52 (01) 132-139 , discussion 139
• 17 Schuette AJ, Cawley CM, Barrow DL. Indocyanine green videoangiography in the management of dural arteriovenous fistulae. Neurosurgery 2010; 67 (03) 658-662 , discussion 662
• 18 Colby GP, Coon AL, Sciubba DM, Bydon A, Gailloud P, Tamargo RJ. Intraoperative indocyanine green angiography for obliteration of a spinal dural arteriovenous fistula. J Neurosurg Spine 2009; 11 (06) 705-709
• 19 Patel NP, Birch BD, Lyons MK, DeMent SE, Elbert GA. Minimally invasive intradural spinal dural arteriovenous fistula ligation. World Neurosurg 2013; 80 (06) e267-e270
• 20 On Tsang AC, Hang Tse PY, Ting Ng GH, Kit Leung GK. Minimal access microsurgical ligation of spinal dural arteriovenous fistula with tubular retractor. Surg Neurol Int 2015; 6: 99
• 21 Hayashi K, Horie N, Morofuji Y, Fukuda S, Yamaguchi S, Izumo T. Intraoperative angiography using portable fluoroscopy unit in the treatment of vascular malformation. Neurol Med Chir (Tokyo) 2015; 55 (06) 505-509
• 22 Nossek E, Chalif DJ, Buciuc R. et al. Intraoperative angiography for arteriovenous malformation resection in the prone and lateral positions, using upper extremity arterial access. Oper Neurosurg (Hagerstown) 2017; 13 (03) 352-360