Endovascular operating suite: future directions for treating neurovascular disease

The use of hybrid operating rooms in neurosurgery, advantages, disadvantages, and future perspectives: a systematic review

BACKGROUND

Hybrid operating rooms (hybrid-ORs) combine the functionalities of a conventional surgical theater with the advanced imaging technologies of a radiological suite. Hybrid-ORs are usually equipped with CBCT devices providing both 2D and 3D imaging capability that can be used for both interventional radiology and image guided surgical applications. Across all fields of surgery, the use of hybrid-ORs is gaining in traction, and neurosurgery is no exception. We hence aimed to comprehensively review the use of hybrid-ORs, the associated advantages, and disadvantages specific to the field of neurosurgery.

MATERIALS AND METHODS

Electronic databases were searched for all studies on hybrid-ORs from inception to May 2022. Findings of matching studies were pooled to strengthen the current body of evidence.

RESULTS

Seventy-four studies were included in this review. Hybrid-ORs were mainly used in endovascular surgery (n = 41) and spine surgery (n = 33). Navigation systems were the most common additional technology employed along with the CBCT systems in the hybrid-ORs. Reported advantages of hybrid-ORs included immediate assessment of outcomes, reduced surgical revision rate, and the ability to perform combined open and endovascular procedures, among others. Concerns about increased radiation exposure and procedural time were some of the limitations mentioned.

CONCLUSION

In the field of neurosurgery, the use of hybrid-ORs for different applications is increasing. Hybrid-ORs provide preprocedure, intraprocedure, and end-of-procedure imaging capabilities, thereby increasing surgical precision, and reducing the need for postoperative imaging and correction surgeries. Despite these advantages, radiation exposure to patient and staff is an important concern.

Clinical outcomes of procedures combining endovascular embolization with a direct surgical approach in a hybrid operating room for the treatment of refractory dural arteriovenous fistulas

Background:

We reviewed the clinical outcomes of a procedure that combines endovascular embolization and a direct surgical approach in a hybrid operating room (OR) for the treatment of refractory dural arteriovenous fistulas (dAVFs).

Methods:

All patients with intracranial dAVFs who underwent a procedure combining endovascular embolization and direct surgical approach with biplane angiography or a robotic C-arm system in a hybrid OR between February 2004 and June 2020 were considered. Borden grading, occlusion rate, pre-and post-operative modified Rankin Scale (mRS) scores, and complications were retrospectively investigated. The pre-and postoperative mRS scores were compared using the Wilcoxon signed-ranks test.

Results:

We evaluated 14 arteriovenous fistulas (AVFs) in consecutive 13 patients. Of these, ten AVFs were previously treated with endovascular embolization, ten were located in the transverse-sigmoid sinus, and four in the cortical vein. The Borden grade was II in two AVFs and III in 12 AVFs. Immediate occlusion of the AVF was achieved in 13 AVFs, and gradual occlusion was observed in one case. The median preoperative mRS was 1 (0–3), whereas the median postoperative mRS was 0 (0–1) which indicated marked improvement (P = 0.006). Complications including postoperative transient visual disturbance and intraprocedural extravasation were observed in only two cases.

Conclusion:

The combination of endovascular embolization and direct surgical approach in a hybrid OR could achieve sufficient occlusion of refractory AVFs with acceptable complication rates and improved symptoms.

Combined Endovascular and Surgical Treatment for Brain Arteriovenous Malformations in Biplanar Hybrid Operating Room

OBJECTIVE

Combined surgical and endovascular treatment for vascular disorders has become prevalent in recent years. However, reports on one-session hybrid surgery for arteriovenous malformations (AVMs) are relatively rare. The safety and efficiency of combined treatment for brain AVMs were analyzed in biplanar hybrid operating room (OR) at one stage.

METHODS

We retrospectively analyzed 20 patients with AVMs undergoing combined surgical and endovascular treatment from October 2015 to June 2018. The data for resection rate, microcatheter adhesion, surgical position and postoperative outcomes were analyzed. Total resection or near-total resection was achieved in all cases.

RESULTS

A total of 13 patients were under combined endovascular and surgical procedures, and 7 experienced surgery with intraoperative digital subtraction angiography. Sitting position was applied in 3 of them; 2 niduses in cerebellum, and 1 in parietal lobe. Compared with admission modified Rankin Scale (mRS) in all patients, postoperative 12-month mRS showed a significant decline. Besides, 3 patients experienced microcatheter adhesion after endovascular embolization, thereafter underwent surgical adhesion removal while nidus resection was done.

CONCLUSION

Combined endovascular and surgical modality in a hybrid OR at one stage provides a safe strategy for the treatment of AVMs. The biplanar hybrid neurointerventional suite is endowed with unconstrained operating angle which enables combined endovascular and surgical treatment in sitting position. It also reduces the risk of microcatheter adhesion, which enables interventional radiologists to perform aggressively.

Treating cerebrovascular diseases in hybrid operating room equipped with a robotic angiographic fluoroscopy system: level of necessity and 5-year experiences

BACKGROUND

A hybrid operating room (OR) equipped with robotic angiographic fluoroscopy system has become prevalent in neurosurgery. The level of necessity of the hybrid OR in treating cerebrovascular diseases (CVD) is rarely discussed.

OBJECTIVE

The authors proposed a scoring and classification system to evaluate the cerebrovascular procedures according to the level of treatment necessity for CVD in a hybrid OR and shared our 5-year experiences.

METHODS

From December 2009 to January 2016, the registry of cerebrovascular procedures performed in the hybrid OR was retrieved. A scoring system was used to evaluate the importance of the surgical and interventional components of a cerebrovascular procedure performed in the hybrid OR. The score of either component ranged from 1, 1.5, to 2 (1 = no role, 1.5 = supplementary or informative, 2 = important or therapeutic). The total score of a procedure was by multiplying two individual scores. Levels of necessity were classified into level A (important), level B (beneficial), and level C (replaceable).

RESULTS

A total of 1027 cerebrovascular procedures were performed during this period: diagnostic angiography in 328, carotid artery stenting in 286, aneurysm coiling in 128, intra-operative DSA in 101, aspiration of ICH under image guidance in 79, intra-arterial thrombolysis/thrombectomy in 51, intracranial angioplasty/stenting in 30, hybrid surgery/serial procedures in 19, and rescue surgery during embolization in 5. According to the scoring system, hybrid surgery and serial procedures scored the highest points (2 × 2). The percentages distributed at each level: levels A (2.3%), B (17.5%), and C (80.2%).

CONCLUSION

This study conveys a concept of what a hybrid OR equipped with robotic angiographic fluoroscopy system is capable of and its potential. For cerebrovascular diseases, hybrid OR exerts its value via hybrid surgery or avoiding patient transportation in serial procedures (level A), via providing real-time high-quality angiography and image guidance (level B), which constituted about 20% of the cases. The subspecialty of the group using the hybrid OR directly reflects on the number of procedures categorized in each level. In a hybrid OR, innovative treatment strategies for difficult-to-treat CVD can be developed.

Hybrid Operating Room for Combined Neuroendovascular and Endoscopic Treatment of Ruptured Cerebral Aneurysms with Intraventricular Hemorrhage

BACKGROUND

Intraventricular hemorrhages (IVHs) caused by ruptured cerebral aneurysms often have poor outcomes. Treatment challenges include comorbidities, increased intracranial pressure caused by IVH, and risk of rebleeding.

CASE DESCRIPTION

Two cases of severe IVH accompanied by acute hydrocephalus caused by ruptured aneurysm were treated with coil embolization followed by endoscopic hematoma evacuation as a single treatment session in a hybrid operating room (OR) equipped with a multipurpose angio biplane system. The first case was an 84-year-old woman with a ruptured basilar top aneurysm, who presented with Hunt and Hess (H&H) grade 5 subarachnoid hemorrhage (SAH) with packed IVH. The second case was a 43-year-old man with a ruptured anterior communicating artery aneurysm who presented with H&H grade 5 SAH with packed IVH. In both cases, endovascular coil embolization was performed first to prevent intraoperative bleeding. The coiled aneurysms suddenly appeared on the screen of the endoscope during the hematoma removal, which could have led to massive rebleeding if not treated previously. Neither patient needed a reinsertion of the ventricular drainage or developed chronic hydrocephalus during hospitalization. The hybrid OR enabled the 2 treatment approaches to be performed without the need to transfer the patient, thereby minimizing the transition time between the modalities. Intraoperative cone-beam computed tomography contributed to the evaluation of residual clots.

CONCLUSIONS

A hybrid OR may contribute to a combined neuroendoscopic and endovascular treatment for ruptured cerebral aneurysms with severe intraventricular hemorrhage.

Intraoperative angiography reloaded: a new hybrid operating theater for combined endovascular and surgical treatment of cerebral arteriovenous malformations: a pilot study on 25 patients

BACKGROUND

Multimodality treatment suites for patients with cerebral arteriovenous malformations (AVM) have recently become available. This study was designed to evaluate feasibility, safety and impact on treatment of a new intraoperative flat-panel (FP) based integrated surgical and imaging suite for combined endovascular and surgical treatment of cerebral AVM.

METHODS

Twenty-five patients with AVMs to treat with combined endovascular and surgical interventions were prospectively enrolled in this consecutive case series. The hybrid suite allows combined endovascular and surgical approaches with intraoperative scanner-like imaging (XperCT®) and intraoperative 3D rotational angiography (3D-RA). The impact of intraoperative multimodal imaging on feasibility, workflow of combined interventions, surgery, and unexpected imaging findings were analyzed.

RESULTS

Twenty-five patients (mean age 38 ± 18.6 year) with a median Spetzler-Martin grade 2 AVM (range 1-4) underwent combined endovascular and surgical procedures. Sixteen patients presented with a ruptured AVM and nine with an unruptured AVM. In 16 % (n = 4) of cases, intraoperative imaging visualized AVM remnants ≤3 mm and allowed for completion of the resections in the same sessions. Complete resection was confirmed in all n = 16 patients who had follow-up angiography one year after surgery so far. All diagnostic and therapeutical steps, including angiographic control, were performed without having to move the patients

CONCLUSION

The hybrid neurointerventional suite was shown to be a safe and useful setup which allowed for unconstrained combined microsurgical and neuroradiological workflow. It reduces the need for extraoperative angiographic controls and subsequent potential surgical revisions a second time, as small AVM remnants can be detected with high security.

Justification of unruptured intracranial aneurysm repair: a single-center experience

BACKGROUND AND PURPOSE

Whether to treat UIAs is controversial. The aim of the study was to compare the clinical outcome of patients with UIAs who were either treated conservatively or preventively.

MATERIALS AND METHODS

Patients with UIAs referred to our institution were prospectively enrolled in the study. Data collected included baseline characteristics, aneurysmal features, and procedural and follow-up information. Preventive treatment was recommended if the aneurysm was larger than 5 mm and was considered safely treatable. Endovascular surgery was the first-line therapy if the aneurysmal shape was appropriate for coiling.

RESULTS

From January 2003 through April 2008, a total of 879 patients with 1110 UIAs were enrolled; 325 patients with 369 UIAs (mean size, 7.8 mm) were treated (treatment group), and 603 patients with 741 UIAs (mean size, 4.4 mm) were managed conservatively (observation group). Mean follow-up was 692.5 days (1405.5 person-years). In the observation group, 26 aneurysms (3.5%) had ruptured (1.8% per year; 1405.5 person-years), 10 patients died, and 7 were disabled (mRS, 3-6: 2.8%). Aneurysmal size was a significant risk factor for rupture (P = .001). The treatment group included aneurysms treated either with coiling (n=315), clipping (n=32), or a combined approach (n=9); 1 patient died, and 3 were disabled (mRS, 3-6: 1.2%). Therapeutic intervention was equal (UIAs of all sizes) or superior (UIAs > 5 mm; P = .025) to conservative management.

CONCLUSIONS

Treatment of UIAs was justified in aneurysms larger than 5 mm, and EVS can be safely applied to nearly 90% of UIAs.

A novel technique for ventriculoperitoneal shunting by flat panel detector CT-guided real-time fluoroscopy

Background:

Surgical placement of a ventriculoperitoneal shunt (VPS) is the main strategy to manage hydrocephalus. However, the failure rate associated with placement of ventricular catheters remains high.

Methods:

A hybrid operating room, equipped with a flat-panel detector digital subtraction angiography system containing C-arm cone-beam computed tomography (CB-CT) imaging, has recently been developed and utilized to assist neurosurgical procedures. We have developed a novel technique using intraoperative fluoroscopy and a C-arm CB-CT system to facilitate accurate placement of a VPS.

Results:

Using this novel technique, 39 consecutive ventricular catheters were placed accurately, and no ventricular catheter failures were experienced during the follow-up period. Only two patients experienced obstruction of the VPS, both of which occurred in the extracranial portion of the shunt system.

Conclusion:

Surgical placement of a VPS assisted by flat panel detector CT-guided real-time fluoroscopy enabled accurate placement of ventricular catheters and was associated with a decreased need for shunt revision.

Robotic Digital Subtraction Angiography Systems Within the Hybrid Operating Room

BACKGROUND:

Fully equipped high-end digital subtraction angiography (DSA) within the operating room (OR) environment has emerged as a new trend in the fields of neurosurgery and vascular surgery.

OBJECTIVE:

To describe initial clinical experience with a robotic DSA system in the hybrid OR.

METHODS:

A newly designed robotic DSA system (Artis zeego; Siemens AG, Forchheim, Germany) was installed in the hybrid OR. The system consists of a multiaxis robotic C arm and surgical OR table. In addition to conventional neuroendovascular procedures, the system was used as an intraoperative imaging tool for various neurosurgical procedures such as aneurysm clipping and spine instrumentation.

RESULTS:

Five hundred one neurosurgical procedures were successfully conducted in the hybrid OR with the robotic DSA. During surgical procedures such as aneurysm clipping and arteriovenous fistula treatment, intraoperative 2-/3-dimensional angiography and C-arm-based computed tomographic images (DynaCT) were easily performed without moving the OR table. Newly developed virtual navigation software (syngo iGuide; Siemens AG) can be used in frameless navigation and in access to deep-seated intracranial lesions or needle placement.

CONCLUSION:

This newly developed robotic DSA system provides safe and precise treatment in the fields of endovascular treatment and neurosurgery.

Intraoperative angiography during microsurgical removal of arteriovenous malformations in children

OBJECT

Confirming the successful management of pediatric arteriovenous malformations (AVMs) requires high-quality postoperative digital subtraction angiography. Although the role of intraoperative angiography during the microsurgical removal of AVMs is well established in adults, the technique has several limitations including poor image quality, uniplanar image acquisition, and absent full heparin protection. Here, the authors report on their experience with high-quality intraoperative angiography during the surgical management of pediatric AVMs in their image-guided therapy (IGT) facility.

METHODS

The authors retrospectively reviewed the demographic, clinical, and radiological characteristics of 22 patients who underwent the surgical management of AVMs at the Hospital for Sick Children in Toronto, with the aid of high-quality intraoperative or immediate postresection cerebral angiography via a transfemoral approach.

RESULTS

Between January 2000 and August 2009, 18 children (mean age 13.05 ± 4.04 years, range 4-21 years) underwent both surgical management of an AVM and intraoperative cerebral angiography at an IGT facility. An additional 4 children underwent angiography immediately after surgery in the regular operating room while under the same anesthesia. The mean AVM size was 2.55 ± 1.43 cm (range 1-6 cm) with a mean Spetzler-Martin grade of 2.27 (range 1-4). Intraoperative angiography in 4 of the 18 patients demonstrated residual AVM requiring additional resection. One patient demonstrated residual AVM on immediate postoperative angiography and underwent immediate reoperation. Successful excision of the residual AVM was confirmed on angiography the following day in that case. Procedural complications occurred in connection with 1 (3.3%) of 30 angiograms, including asymptomatic transient nonfilling of an ophthalmic artery, which was resolved on follow-up angiography. Negative intraoperative angiograms were confirmed with follow-up angiograms in 15 (93.75%) of 16 patients at a mean of 9.93 ± 5.70 months. One patient with a negative intraoperative angiogram demonstrated a tiny residual AVM on follow-up angiography at 8 months (false-negative rate 6.25%), but had a negative preoperative angiogram 1 year later in the IGT facility. No patient with a negative intraoperative angiogram required further AVM-directed treatment.

CONCLUSIONS

Intraoperative angiography is a safe and effective adjunct to the surgical management of AVMs in children. This novel approach allows the pre-, intra-, and postoperative acquisition of high-quality images, which can help guide the resection of AVMs, especially those that are small, diffuse, or of a complex angioarchitecture.

Intraoperative biplanar rotational angiography during neurovascular surgery

Object

The purpose of this study was to evaluate the authors' initial experience with the integration of high-resolution rotational and biplanar angiography during neurovascular operative procedures.

Methods

Eight patients with intracerebral arteriovenous malformations (AVMs) and aneurysms underwent surgical treatment of their lesions in a combined endovascular surgical suite. After initial head positioning, preoperative biplane and rotational angiography was performed. Resection of the AVM or clipping of the aneurysm was then performed. Further biplane and rotational 3D angiograms were obtained intraoperatively to confirm satisfactory treatment.

Results

One small residual AVM identified intraoperatively necessitated further resection. One aneurysm was clipped during endovascular inflation of an intracarotid balloon for temporary proximal control. The completeness of treatment was confirmed on intraoperative 3D rotational angiography in all cases, and there were no procedure-related complications.

Conclusions

Intraoperative rotational angiography performed in an integrated biplane angiography/surgery suite is a safe and useful adjunct to surgery and may enable combining endovascular and surgical procedures for the treatment of complex vascular lesions.

[Anesthesia in interventional neuroradiology]

Interventional neuroradiology procedures have become increasingly complex, requiring planning and coordination. Key roles are played by the anesthesiologist and the radiologist, as well as by technicians and nurses. This review aims to analyze the anesthesiologist's part in managing these procedures, from the start of the intervention through the immediate postoperative period. First concerns are to assure patient safety during transfer, maintain the airway, keep the patient immobile and hemodynamically stable, and manage anticoagulant and antiplatelet treatments. Rapid awakening must also be assured so that the patient's neurologic status can be assessed in situ. The anesthesiologist should treat any neurologic complications that develop and that might lead to emergency situations during the procedures.

Dynact soft-tissue visualization using an angiographic C-arm system: initial clinical experience in the operating room

INTRODUCTION

DynaCT is a clinical application protocol to create computed tomographic (CT)-like images allowing soft-tissue visualization acquired from an angiography system. A cone beam three-dimensional CT reconstruction is produced from the acquisition of two-dimensional projection images by rotating the c-arm with x-ray source and image receptor around the patient. The purpose of this study is to evaluate the clinical efficacy of DynaCT in the operating room.

METHODS

DynaCT was performed in 100 patients undergoing cerebral or spinal interventional procedures in the new-concept operating room. Specially designed AXIOM Artis BA (conventional image intensifier system; 55 patients; Siemens Medical Solutions, Erlangen, Germany) and AXIOM Artis dBA (flat-panel detector; 45 patients; Siemens Medical Solutions) biplane neuroangiographic systems (Siemens Medical Solutions, Germany) were installed in the operating room. The volumetric data set from the AXIOM Artis systems were reconstructed immediately on the three-dimensional workstation in the operating room. We compared DynaCT images with the use of multidetector computed tomography.

RESULTS

DynaCT was performed successfully in all patients. High-contrast structures, such as bone, calcified lesions, and metallic materials, were visualized on DynaCT as well as in multidetector computed tomography for each group. Although contrast differentiation of soft tissue such as cerebral cortex, muscle, and hematoma on DynaCT were inferior to multidetector CT scans, the images were sufficiently used as intraoperative CT-like images. However, DynaCT images acquired from flat panel detector-based systems were found to be superior to those images acquired from image intensifier-based systems. Striking ring artifacts were exhibited and resulted in major limitations in the image intensifier group.

CONCLUSION

DynaCT has the potential to be used as a powerful tool for endovascular and neurosurgical procedures and will open new possibilities for neurosurgical management.