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Intraoperative angiography via popliteal artery access for spinal neurovascular lesions: an institutional experience and systematic review
  1. Najib Muhammad1,
  2. Georgios S Sioutas1,
  3. Avi Gajjar1,
  4. Mohamed M Salem1,
  5. Sandeep Kandregula2,
  6. Visish M Srinivasan1,
  7. Brian T Jankowitz1,
  8. Jan-Karl Burkhardt1
  1. 1 Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
  2. 2 Neurosurgery, LSU Health Shreveport, Shreveport, Louisiana, USA
  1. Correspondence to Dr Jan-Karl Burkhardt, Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania 19104, USA; jankarl.burkhardt{at}


Background Intraoperative DSA is used to confirm complete obliteration of neurovascular pathologies. For spinal neurovascular lesions, femoral access can be challenging given the need to flip the patient after sheath placement. Similarly, radial access can be complicated by arch navigation difficulties. Vascular access via the popliteal artery represents an appealing alternative option; however, data regarding its utility and efficacy in these cases are limited.

Methods A retrospective series of four consecutive patients between July 2016 and August 2022 who underwent intraoperative spinal DSA via the popliteal artery was analyzed. Additionally, a systematic review was conducted to collect previously reported such cases. Collective patient demographics and operative details are presented to consolidate the available evidence supporting popliteal access.

Results Four patients met the inclusion criteria from our institution. The systematic review yielded six previously published studies reporting 16 additional transpopliteal access cases. Of the 20 total cases (mean±SD age 60.8±17.2 years), 60% were men. Most treated lesions were dural arteriovenous fistulas (80%) located in the thoracic spine (55%) or cervical spine (25%). The left popliteal artery was most accessed and the highest visualized level was the craniocervical junction. All outcomes were either stable or improving after surgery, and no complications were observed.

Conclusions We report the safety and feasibility of transpopliteal access for intraoperative DSA in the prone position in four cases in addition to 16 previously reported cases in the literature. Our case series highlights popliteal artery access as an alternative to transfemoral or transradial access in this setting.

  • Angiography
  • Malformation
  • Technique

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Twitter @GSSioutas, @aviagajjar, @MMSalemMD, @DrKandregula, @visishs, @BrianJankowitz, @JanKarlBurkhar1

  • Contributors All authors made substantial contributions. Study conception/design: JKB. Data acquisition and analysis: NM, GSS, AG, MMS, and SK. Data interpretation: all authors. Manuscript drafting: NM, GS, MMS. Critical revision of the manuscript for important intellectual content: all authors. Approval of final version of the manuscript: all authors. Guarantor of the study: JKB.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.