Case for Intraoperative Angiogram

Introduction: Intraoperative angiography (IOA) has been an operative adjunct in the repair of vascular lesions since the 1960s, allowing for immediate resolution of intraoperative complications. Intraoperative surgical revision for incomplete aneurysm occlusion or parent vessel occlusion in aneurysm clipping, incomplete AVM obliteration, or revision in CEA has been cited at 12%, 8-11%, and 6%, respectively.

Methods: We sought compare the rates of averted complications and potential reoperations with use of IOA for open aneurysm repair, AVM resection, and carotid endarterectomy. Using a retrospective database, data was obtained from July 2021 to June 2023 in which there were 58 aneurysm clippings, AVM resections, and CEAs performed by a single surgeon.

Results: Of 18 aneurysm cases, 12 (66%) underwent IOA. Of those, 5 (41.6%) underwent adjustment of the clip position (3 for incomplete occlusion, 2 for flow-limiting stenosis or parent vessel occlusion). Twelve (86%) of 14 AVMs underwent IOA, with 1 (8.3%) requiring further resection for residual nidus. Finally, we performed IOA in 24 (96%) of 25 CEAs, three (12.5%) of which required further intervention (1 distal thrombus that resolved with additional heparin, and 2 with residual stenosis that was revised and corrected). Among all patients undergoing IOA (48), nine patients (18.8%) underwent surgical revision during the procedure and avoided a potential complication, and only one (2.1%) patient required a second operation for the surgically addressed pathology. That patient had a Spetzler-Martin II deep left parieto-occipital AVM with slow flow through a small residual nidus adjacent to the craniotomy, identified on subsequent angiography and then received gamma knife radiosurgery without complication.

Conclusion : In this cohort, intraoperative angiography averted potential complications in 18.8% of open cerebrovascular procedures and led to more definitive cure of the addressed pathologies (97.9%). The immediate intraoperative correction afforded by IOA has contributed to improved patient outcomes, decreased complication rates, and a decreased need for re-operation.