International teleproctoring in neurointerventional surgery and its potential impact on clinical trials in the era of COVID-19: legal and technical considerations.

BACKGROUND: Existing travel restrictions limit the mobility of proctors, significantly delaying clinical trials and the introduction of new neurointerventional devices. We aim to describe in detail technical and legal considerations regarding international teleproctoring, a tool that could waive the need for in-person supervision during procedures. METHODS: International teleproctoring was chosen to provide remote supervision during the first three intracranial aneurysm treatments with a new flow diverter (currently subject of a clinical trial) in the US. Real-time, high-resolution transmission software streamed audiovisual data to a proctor located in Canada. The software allowed the transmission of images in a de-identified, HIPAA-compliant manner. RESULTS: All three flow diverters were implanted as desired by operator and proctor and without complication. The proctor could swap between images from multiple sources and reported complete spatial and situational awareness, without any significant lag or delay in communication. Procedural times and radiologic dose were similar to those of uncomplicated, routine flow diversion cases at our institution. CONCLUSIONS: International teleproctoring was successfully implemented in our clinical practice. Its first use provided important insights for establishing this tool in our field. With no clear horizon for lifting the current travel restrictions, teleproctoring has the potential to remove the need for proctor presence in the angiography suite, thereby allowing the field to advance through the continuation of trials and the introduction of new devices in clinical practice. In order for this tool to be used safely and effectively, highly reliable connection and high-resolution equipment is necessary, and multiple legal nuances have to be considered.

Cervical ribs: identification on MRI and clinical relevance.

To determine the prevalence of cervical ribs on cervical spine MRI and clinical relevance, we reviewed 2500 studies for cervical ribs and compression of neurovascular structures and compared to CT, when available. Brachial plexus or subclavian artery contact by cervical rib was identified on MRI and/or CT in 12 cases with diagnosis of thoracic outlet syndrome in one. Cervical ribs were identified on 1.2% (25/2083) of examinations, lower than on CT (2%), but MRI may offer equivalent anatomic explanation for patient symptoms.

Adductor magnus perforator flap revisited: an anatomical review and clinical applications.

BACKGROUND: The adductor magnus musculocutaneous perforator flap is a medial thigh flap whose utility is often overshadowed by that of its anatomic neighbor, the gracilis flap. It has a large, reliable pedicle and associated skin paddle. Few reports have been published describing the use of this flap as a local or free tissue transfer. The purpose of this study is to revisit and further characterize the anatomy of this extremely versatile yet underutilized flap. MATERIALS/METHODS: A total of 13 cadavers (n = 26 thighs) were dissected to identify the musculocutaneous perforators that supply the skin of the posteriomedial thigh. The vascular anatomy was studied using multiple modalities. Based on the anatomic data, a local V-Y advancement flap was designed. A total of 8 patients (n = 10 flaps) underwent reconstruction of locoregional defects. RESULTS: Our anatomic studies confirmed the presence of multiple parallel musculocutaneous perforators that travel through the adductor magnus muscle and course obliquely in a posterior-inferior direction. We found that the primary perforator is reliably found approximately 8 cm distal to the groin crease and 2 cm posterior to the posterior border of the gracilis muscle. We discovered that it is consistently accompanied by a separate perforator located 2 cm distally. Minimal dissection into the muscle revealed a Y-configuration of these 2 perforators. This configuration was present in 100% of the cadaveric dissections and is supplied by the first medial branch of the profunda femoris artery. Computed tomography angiograms depicted vascular arborization of the perforators supplying the flap. Clinical experience showed that complete flap survival was achieved in all of the cases. CONCLUSION: The adductor magnus perforator flap is a reliable flap that offers robust blood supply, through a consistent vascular pedicle, to an extensive skin territory. Our anatomic studies revealed the consistent presence of 2 proximal perforators in the medial thigh that are linked by an intramuscular Y-configuration that provides enhanced blood supply to a local V-Y advancement flap design. The location of the skin paddle on the proximal medial thigh allows for minimal donor-site morbidity as it can be closed primarily with a V-Y advancement flap design, obviating the need for skin grafting.

Semi-jailing technique for coil embolization of complex, wide-necked intracranial aneurysms.

OBJECTIVE: Stent-assisted coiling of intracranial aneurysms is performed by placing a microcatheter through a stent's interstices or jailing the microcatheter between the stent and the artery. Both approaches impede manipulation of the microcatheter during coiling. We describe a modified jailing technique that improves catheter maneuverability and report the safety and efficacy of the method for the treatment of complex, wide-necked aneurysms. METHODS: The semi-jailing technique involves the partial deployment of a retrievable stent, bridging part of the aneurysm neck while leaving space to maneuver the microcatheter. Twenty-two complex, wide-necked aneurysms, including 3 ruptured and 5 dissecting, were treated using the semi-jailing technique (15 women; mean age, 55.2 years). RESULTS: The semi-jailing technique was successfully applied in all cases. Immediate posttreatment angiograms showed total occlusion of the aneurysm in 17 cases (77%), neck remnant in 3 cases (14%), and aneurysm dome filling in 2 cases (9%). Follow-up angiography available in 10 patients at an average of 8.5 months showed progressive occlusion in 1 aneurysm and 7 remained occluded. In 2 cases of dissecting aneurysms, retreatment was required. No permanent periprocedural morbidity was encountered. One patient died of complications secondary to intracranial hemorrhage 6 days after treatment. In 2 cases (9%), thromboembolic events after final stent placement were successfully treated with intraarterial thrombolysis. No delayed stent migration was seen. CONCLUSION: Semi-jailing is a safe and effective stent-assisted coiling technique that facilitates treatment of complex, wide-necked aneurysms.