Surgical exposure of the vertebral artery for endovascular access in a hybrid operating room.

PURPOSE: Endovascular procedures are a desirable treatment option for neurovascular lesions in posterior circulation. However, endovascular access occasionally fails due to tortuosity of the proximal vertebral artery (VA), aortic arch, and/or VA ostium stenosis. We aimed to describe the creation of endovascular access via surgical exposure of the VA in a hybrid operating room to overcome anatomical difficulties hampering distal access to the VA through the transfemoral or transradial approach. METHODS: We present six patients with seven posterior circulation lesions in whom distal access via the conventional approach to the VA was impossible. Surgical exposure of the VA was performed to provide endovascular access to these patients. Radiographic characteristics, operative techniques, and outcomes were reviewed. RESULTS: Surgical exposure of the VA was performed in six patients with cerebral aneurysm (n = 4) and symptomatic stenosis of the VA ostium (n = 3). There were four female and two male patients, aged 73-82 years. Surgical exposure was usually performed beyond the tortuous segments of the VA. After endovascular access was provided, coil embolization was performed for cerebral aneurysms and/or balloon angioplasty and stenting was performed to treat the VA ostium stenosis. All puncture sites were closed by direct suture using a 7-0 Prolene suture. All procedures were completed without adverse events. CONCLUSION: Endovascular access via surgical exposure of the VA is a feasible and safe alternative for patients in whom the femoral or radial route does not allow the navigation and stabilization of the guiding catheter into the proximal segment of the VA.

A hybrid operating room for combined surgical and endovascular procedures for cerebrovascular diseases: a clinical experience at a single centre.

Purpose: To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR). Material and methods: A single-plane DSA system with 3-dimensional rotational angiography (3DRA), cone-beam computed tomography, and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of neurovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorised into five subcategorical procedures according to the dominance of surgical and/or endovascular procedures: intraoperative angiographic evaluation, combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, surgical approach for interventional procedure, and frameless stereotaxic operation. Results: Intraoperative angiography revealed unsatisfactory clipping of intracranial aneurysms in 6 (13.6%) patients and remnant AVMs in 1 (16.7%) patient, which were determined as complete surgical outcome via indocyanine green videoangiography. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial haemorrhage (ICH) were treated by partial embolisation and surgical clipping. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolisation. In 1 (0.8%) complicated case of 103 intra-arterial (IA) thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. Direct puncture of the common carotid artery or vertebral artery was performed to achieve interventional access to treat aneurysm or recanalise vessel occlusions in 7 cases. In 27 cases of ICH, frameless stereotaxic haematoma aspiration was performed using XperGuide® system. All procedures were performed in single sessions without any procedural complications. Conclusion: Hybrid OR with a fully equipped DSA system could provide safe and precise treatment for neurovascular diseases. Hybrid procedures for neurovascular diseases in hybrid OR are a promising new trend.