Refining Intraoperative Angiography in the Prone Position
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LETTER TO THE EDITOR
Refining Intraoperative Angiography in the Prone Position Anderson Chun On Tsang1
· Andrew Cheuk Him Ho1 · Wai Man Lui1
Received: 3 July 2020 / Accepted: 27 August 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Editor, We read with great interest the paper by Wang et al. on the technical aspects of intraoperative transfemoral angiography in the prone or three-quarter prone position [1], and commend the authors’ effort in describing the technique in detail. Intraoperative angiograms can be challenging if the operating team is unfamiliar with the set-up, leading to resistance in adopting this useful practice to ensure angiographical cure of cerebral and spinal vascular lesions. As a dual-trained open and endovascular neurosurgical team, we have been routinely performing intraoperative angiography to confirm definitive obliteration of arteriovenous shunting lesions before craniotomy closure and have performed 65 such procedures to date. We would like to share our experience and supplement the technical nuances described by the authors. The key to smooth and successful intraoperative angiography lies in preoperative preparation and positioning of the patient as well as the shoulder or chest support attachments, especially for three-quarter prone or lateral and sit-up positions. Aside from using radiolucent headframe and attachments, it is important to avoid obscuring the upper chest at the level of the aortic arch to facilitate catheterization of the subclavian and carotid arteries. Prior communication with the anesthesiologist is essential as extra attention is required for the placement of intraoperative monitoring cables utilized in brain arteriovenous malformation surgeries to ensure they do not cross the field of interest during angiography. These include subdermal needles for motor and somatosensory evoked potential, bispectral index electrodes for depth of anesthesia monitoring, and electrocardiogram cables.
During craniotomy, we made a conscious effort to avoid placing metallic or radiopaque equipment over the surgical field. Stay sutures for skin and dura retraction are used instead of metallic wound retractors and staplers (e.g. Fig. 3a, d, k in the original paper). Surgical tools and connecting wires (such as bipolar forceps, high-speed drill, suction tubes) are atemporarily removed during angiography to avoid imaging interference. If a hybrid operating theatre with angiography table is not available, intraoperative angiogram can also be performed with modern radiolucent operating table (e.g. Allegro mobile imaging table, Mizuho, Tokyo, Japan) and a mobile C-arm fluoroscopy machine. Regarding the extended femoral arterial sheath, instead of using NeuronMax 80 cm (Penumbra, Alameda, CA, USA) we routinely used stainless steel reinforced kink-resistant sheath of 35 cm (Super Arrow-flex sheath, Teleflex Inc, Plymouth, MN, USA) and found it adequate to provide enough length over the lateral thigh for access in the prone position after draping. Using a shorter shea
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