Objective Venous Sinus Stenting (VSS) is emerging as a promising treatment for Idiopathic Intracranial Hypertension. VSS procedures face certain procedural challenges, including navigation without road-map and the potential risk of occluding large cortical veins (i.e. vein of Labbe) due to the stent. Our group sought to minimize the risks of VSS procedures with new imaging modalities that allow for safer navigation and optimal placement of the stents. The purpose of this study was to evaluate the benefits of a new bi-plane live 3D guidance technique using pre-operative Magnetic Resonance Venogram (MRV) datasets instead of conventional 2D technique.
Methods We performed an IRB approved retrospective evaluation of 80 consecutive patients treated for VSS between Jan-2015 and Feb-2018 (57 with conventional 2D roadmapping only, 23 with additional MRV bi-plane 3D guidance after the software was made available at our institution). The following procedural data where compared between the conventional guidance and the MRV 3D guidance groups: delayed flow in large cortical veins post-stenting, dose area product (DAP), cumulated air kerma (CAK), and fluoroscopy time.
Two experienced neuro-interventionalists, not involved in the treatments, reviewed images from the last 10 MRV 3D guided procedures. At first they reviewed conventional 2D images only and then they reviewed the MRV 3D guided images, and successively assessed their consensus confidence level using a 3-points scale from low to high confidence on the following parameters: venous sinus anatomy, location of large cortical veins, length of venous sinus stenosis and landing zones and length of stent-construct.
Results MRV bi-plane 3D guidance was successful in all cases but one, where registration failed. In the MRV guided group, there was significantly less occurrence of delayed flow in the large cortical veins versus the conventional group (1 vs 8, p<0.001). There were no differences in other procedural parameters (median DAP 148 vs 150 Gy.cm2, p=0.89, median CAK 1496 vs 1603 mGy, p=0.12, and median fluoroscopy time 3035 vs 2758 s, p=0.36).
When comparing conventional images and MRV guided images from the same procedures, there was increased operator confidence regarding the location of the major cortical veins, the length of venous sinus stenosis and the landing zones and the length of stent-construct (1.9 vs 2.9, p=0.002).
Conclusion By better visualization of the large cortical veins and ability to make more accurate measurements in regards to the venous sinus stenosis, MRV bi-plane 3D guidance can improve safety of VSS procedures without any increase in radiation or procedural time.
Disclosures T. Link: None. B. Rapoport: None. G. Avignon: 5; C; General Electric. P. Ozbek: 5; C; General Electric. A. Patsalides: None.
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