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Intraoperative angiography in neurosurgery: temporal trend, access site, and operative indication considerations from a 6-year institutional experience
  1. Thilan Tudor1,
  2. Jonathan Sussman1,2,
  3. Georgios S Sioutas1,
  4. Mohamed M Salem1,
  5. Najib Muhammad1,
  6. Dominic Romeo1,
  7. Antonio Corral Tarbay1,
  8. Yohan Kim1,
  9. Jinggang Ng1,
  10. Isaiah J Rhodes1,
  11. Avi Gajjar1,
  12. Robert W Hurst3,
  13. Bryan Pukenas3,
  14. Linda Bagley3,
  15. Omar A Choudhri1,
  16. Eric L Zager1,
  17. Visish M Srinivasan1,
  18. Brian T Jankowitz1,
  19. Jan-Karl Burkhardt1
  1. 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
  2. 2Graduate Group in Genomics and Computational Biology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Jan-Karl Burkhardt, Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; jan.burkhardt{at}


Background Historically, the transfemoral approach (TFA) has been the most common access site for cerebral intraoperative angiography (IOA). However, in line with trends in cardiac interventional vascular access preferences, the transradial approach (TRA) and transulnar approach (TUA) have been gaining popularity owing to favorable safety and patient satisfaction outcomes.

Objective To compare the efficacy and safety of TRA/TUA and TFA for cerebral and spinal IOA at an institutional level over a 6-year period.

Methods Between July 2016 and December 2022, 317 angiograms were included in our analysis, comprising 60 TRA, 10 TUA, 243 TFA, and 4 transpopliteal approach cases. Fluoroscopy time, contrast dose, reference air kerma, and dose–area products per target vessel catheterized were primary endpoints. Multivariate regression analyses were conducted to evaluate predictors of elevated contrast dose and radiation exposure and to assess time trends in access site selection.

Results Contrast dose and radiation exposure metrics per vessel catheterized were not significantly different between access site groups when controlling for patient position, operative region, 3D rotational angiography use, and different operators. Access site was not a significant independent predictor of elevated radiation exposure or contrast dose. There was a significant relationship between case number and operative indication over the study period (P<0.001), with a decrease in the proportion of cases for aneurysm treatment offset by increases in total cases for the management of arteriovenous malformation, AVF, and moyamoya disease.

Conclusions TRA and TUA are safe and effective access site options for neurointerventional procedures that are increasingly used for IOA.

  • Angiography
  • Aneurysm
  • Arteriovenous Malformation
  • Vascular Malformation
  • Brain

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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  • Contributors TT, JS, and GSS were involved with the writing and editing of the main text and the associated figures and tables. GSS and MMS provided editorial oversight for the manuscript. NM, DR, ACT, YK, JN, IJR, and AG contributed to the development of the intraoperative angiography database. JKB, VMS, BTJ, ELZ, OC, LB, BP, and RWH contributed general and editorial oversight. JKB is the guarantor for the study.

  • 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.