Intraoperative spinal digital subtraction angiography: indications, technique, safety, and clinical impact.
BACKGROUND
Cerebral intraoperative DSA (IODSA) is a well-described, routinely performed procedure that allows the effectiveness of cerebrovascular interventions to be evaluated in the operating room. Spinal IODSA, on the other hand, is infrequently obtained and has received less attention.


OBJECTIVE
To discuss the indications, technique, safety, and clinical impact of spinal IODSA.


METHODS
Twenty-three patients underwent 45 thoracic and/or lumbar spinal IODSA between 2005 and 2016, either immediately before surgery for lesion localization or after the intervention to evaluate its effectiveness. Indications included 21 vascular malformations and 2 diaphragmatic crus compression syndromes. A long femoral arterial sheath with its hub positioned on the lateral surface of the thigh was used to allow catheter manipulations in the prone position.


RESULTS
All targeted intersegmental arteries (ISAs) were successfully catheterized. The course of surgery was changed in 6 instances (26.1%). In 4 cases of epidural or perimedullary arteriovenous fistulae (AVFs), a residual lesion required additional intervention. In one case of epidural AVF, initial IODSA revealed spontaneous resolution of the lesion, preventing unnecessary surgery. Finally, angiography performed in a case of diaphragmatic crus syndrome showed thrombosis of the ISA and non-visualization of the artery of Adamkiewicz. Recanalization was obtained by IA thrombolysis, with excellent clinical outcome. No intraprocedural or postprocedural complication was noted.


CONCLUSIONS
Spinal IODSA is a safe technique that offers an immediate assessment of the effectiveness of a spinovascular surgical procedure, notably epidural and perimedullary AVFs. Spinal IODSA was technically successful in all cases, influencing the surgical strategy in 6 of 23 patients, including one patient who benefited from intraoperative endovascular therapy.
Division of Interventional Neuroradiology, Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
Emanuele
E
Orru'
Division of Interventional Neuroradiology, Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
Danielle E
http://orcid.org/0000-0003-4122-4791
DE
Sorte
Department of Neurological Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
Jean-Paul
JP
Wolinsky
Department of Neurological Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
George I
http://orcid.org/0000-0001-9607-6867
GI
Jallo
Department of Neurological Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
Ali
A
Bydon
Department of Neurological Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
Rafael J
RJ
Tamargo
Division of Interventional Neuroradiology, Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
Philippe
P
Gailloud
D000293:Adolescent; D000328:Adult; D000368:Aged; D015901:Angiography, Digital Subtraction / Q000379:methods*; D001164:Arteriovenous Fistula / Q000000981:diagnostic imaging* / Q000601:surgery*; D002648:Child; D004824:Epidural Space / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D012189:Retrospective Studies; D013116:Spinal Cord / Q000098:blood supply / Q000000981:diagnostic imaging* / Q000601:surgery*; D013904:Thoracic Vertebrae; D055815:Young Adult
Angiography; Arteriovenous Malformation; Fistula; Spinal cord; Vascular Malformation