Original ArticleTen-Year Retrospective Study on the Management of Spinal Arteriovenous Lesions: Efficacy of a Combination of Intraoperative Digital Subtraction Angiography and Intraarterial Dye Injection
Introduction
Spinal arteriovenous lesions are classified as spinal dural arteriovenous fistulas (SDAVFs) (type 1), spinal cord arteriovenous malformations (AVMs) (types 2 and 3), and spinal cord arteriovenous fistulas (AVFs) (type 4) (Figure 1). Spinal arteriovenous lesions are a rare vascular disorder that leads to myelopathy or hemorrhage and have complicated vessel structures. Intradural lesions, in particular, are difficult to completely eliminate.
The goal of treatment of spinal arteriovenous lesions is to reduce blood flow through these lesions and prevent worsening of neurologic function. The optimal treatment for spinal arteriovenous lesions is to completely obliterate the shunt. However, large vessel structures such as varices and aneurysms often hamper detection of the shunt point, making it difficult to completely remove the lesion. Successful surgery depends on the surgeon's ability to identify the implicated vessels and to confirm removal of the lesion. Imaging using computed tomography, magnetic resonance imaging (MRI), or digital subtraction angiography (DSA) is required to obtain clear anatomic visualization. Intraoperative digital subtraction angiography (IODSA) is a useful tool to identify shunt points, the presence of any remaining lesions, and normal vessel structures. However, IODSA is associated with complications, including thrombosis, and may interrupt the surgical procedure, as angiography requires angiographic equipment such as the C-arm. Intravenous indocyanine green (ICG) videoangiography has been reported to be safer, simpler, and more useful than IODSA for the management of spinal arteriovenous lesions.1, 2 This method enables the entire structure of simple lesions to be easily detected, including lesions with a single feeder or drainer vessel. Additionally, in contrast to IODSA, ICG videoangiography does not interrupt the surgical procedure, as it is obtained in real time under microsurgery.
Despite the lower surgical risks and superior detection of simple lesions by ICG compared with IODSA, complex lesions may be difficult to orient using intravenous ICG videoangiography alone. In particular, lesions with multiple feeders and shunts require a large amount of ICG for repeated videoangiography. Moreover, time is required to wash out the ICG, and the stagnation of ICG makes it difficult to repeat the ICG injection immediately. Although some authors3, 4, 5 have reported the effectiveness of intraarterial dye injection (IADI), such as ICG, conclusions have mostly been based on small sample case reports. In addition, previous reports have used 4F (1.33-mm) catheters; drawbacks secondary to catheter migration have been described by Tani et al.4 As such, the efficacy of IADI remains largely unknown.
We describe our 10-year experience of the management of arteriovenous lesions and specifics of the surgical procedure with combined IODSA and IADI. We used intraarterial injection of contrast agent with microcatheters ranging from 1.6F (0.53-mm) to 2.1F (0.69-mm) to avoid catheter migration. This study evaluates the efficacy of our methods for the management of spinal arteriovenous lesions.
Section snippets
Materials and Methods
This study was approved by the ethical committee at Hokkaido University Hospital. We retrospectively investigated 22 patients with spinal arteriovenous lesions who underwent IODSA and IADI at Hokkaido University from July 2006 to July 2016. IODSA was performed in all patients with intradural arteriovenous lesions who underwent open surgery (n = 19), and in patients with SDAVFs (n = 3).
All microsurgical treatments were conducted by 1 of the authors (K. Hi or T. Se), and all IODSA procedures were
Results
Table 1 summarizes the patient demographics, subtypes of spinal arteriovenous lesions, and lesion locations. The study population comprised 9 male and 13 female patients 7–73 years old (average age 35.7 years). These cases included 19 intradural spinal lesions (11 spinal cord AVFs + spinal cord AVMs, 8 spinal cord AVFs) and 3 SDAVFs. There were 29 procedures. Catheterization into arteries was successful in all cases. There was no procedural failure resulting from a kickback of the catheter.
In
Discussion
This study showed that the combination of IODSA and IADI is safe and effective for the treatment of refractory spinal arteriovenous lesions. Moreover, microcatheters prevented the kickback that often causes the failure of target vessels to fluoresce in IADI. IODSA and IADI were safe and effective for treatment of the refractory spinal arteriovenous lesions. Some authors have described the effectiveness of IODSA to detect the vessel structure of spinal arteriovenous lesions.6, 7 IODSA provides
Conclusions
We have described the management of refractory spinal AVFs using multiple techniques of operative monitoring, with retrospective data obtained over a decade. Our findings show that IODSA and IADI together are safe and far more useful to identify whole-vessel structures compared with intravenous ICG videoangiography for complex lesions.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.