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Open surgery
Original research
Combined surgical and endovascular treatment of complex cerebrovascular diseases in the hybrid operating room
  1. Yuichi Murayama1,2,
  2. Hideki Arakawa1,2,
  3. Toshihiro Ishibashi1,2,
  4. Daichi Kawamura2,
  5. Masaki Ebara1,2,
  6. Koreaki Irie1,2,
  7. Hiroyuki Takao1,2,
  8. Satoshi Ikeuchi2,
  9. Takeki Ogawa3,
  10. Masataka Kato2,
  11. Ikki Kajiwara1,2,
  12. Shingo Nishimura1,2,
  13. Toshiaki Abe2
  1. 1Division of Endovascular Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
  2. 2Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
  3. 3Department of Emergency Medicine, The Jikei University School of Medicine, Tokyo, Japan
  1. Correspondence to Dr Yuichi Murayama, Division of Endovascular Neurosurgery, Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo 105-8461, Japan; ymurayama{at}jikei.ac.jp

Abstract

Background Although most neurovascular diseases can be treated either by microsurgical or endovascular means, a subset of patients may require a combined approach. Patient transfer from the operating room (OR) to the angiosuite has been a fundamental drawback of this type of approach.

Objective The purpose of this study is to report our clinical experience performing combined surgical and endovascular procedures for neurovascular diseases in the hybrid OR.

Methods 29 patients with neurovascular diseases underwent combined endovascular and surgical procedures in a single session: 16 were scheduled combined treatment and 13 were emergency combined procedures. Of the emergency cases, three were rescue surgeries after endovascular complications. Three patients had ruptured intracranial aneurysms, eight had unruptured intracranial aneurysms, eight had arteriovenous malformations and eight had arteriovenous fistulae; two patients had either a spinal tumor or dural arteriovenous fistulae.

Results All combined procedures were performed in a single session without changing the patient's surgical position. In cases of ruptured arteriovenous malformations or aneurysms with hematoma, an emergency embolization was performed to assist the surgical procedure. Combined superficial temporal artery–middle cerebral artery (STA–MCA) bypass followed by endovascular parent artery trapping were successfully performed for complex large or giant aneurysms. There were two periprocedural ischemic complications. Of the three patients who underwent surgical rescue after endovascular complications, two remained intact and one died despite immediate surgical procedures.

Conclusion A combined endovascular and surgical approach conducted in a hybrid OR provides a new strategy for the treatment of complex neurovascular diseases.

  • Intervention
  • technology
  • aneurysm
  • bioactive
  • coil
  • device
  • stent
  • stroke
  • ultrasound
  • spine
  • trauma
  • inflammation
  • intervention
  • technique
  • angiography

https://doi.org/10.1136/neurintsurg-2012-010382

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    Introduction

    Over the last two decades, endovascular therapy has been established as an effective treatment for neurovascular disease. Although most vascular lesions, such as cerebral aneurysms, can be treated either by microsurgical or endovascular means, a subset of patients may require a combined approach. Several pioneer works have proved the usefulness of the combined surgical-endovascular approach; however, patient transfer from the operating room (OR) to the angiosuite has been a fundamental drawback of this type of therapeutic approach.1–7

    The recent integration of high-resolution three-dimensional (3D) biplane angiography in the setting of an endovascular and surgical suite has been a promising step towards improved intraoperative diagnostics and endovascular support during neurovascular surgery.8–10

    To achieve a safe and effective endovascular and surgical environment, we have established a new concept: the hybrid endovascular OR for the treatment of neurovascular diseases.9 ,10 Becoming more popular in modern neurosurgery, this type of hybrid OR accommodates the innovations of conventional neurosurgery with those of the widely used minimally invasive endovascular neurosurgery. We present a series of combined endovascular and open surgical procedures performed in single sessions in the hybrid endovascular OR.

    Methods

    Two neurosurgery OR suites were renovated as hybrid endovascular ORs and specially designed digital subtraction angiography (DSA) systems (Axiom Artis dBA and Zeego, Siemens Medical Solutions, Erlangen, Germany) were installed.

    Patient population

    Between November 2003 and August 2011, 29 patients underwent single-session combined endovascular and open surgical procedures. Details of the patients and procedures are shown in table 1. Combined treatment was defined as involving both an endovascular microcatheter technique and a surgical procedure performed in a single session. Patients who underwent simple clipping and intraoperative angiography or combined embolization and ventricular drainage were excluded. Those who underwent scheduled embolization followed by surgical intervention on another day for arteriovenous malformation (AVM)/arteriovenous fistula (AVF) or brain tumor were also excluded from the analysis. Indications for single-session combined procedures were discussed among the neurosurgeons in the team. For large or giant intracranial aneurysms presenting with mass effect, a low-flow superficial temporal artery–middle cerebral artery (STA–MCA) bypass followed by immediate endovascular trapping was planned to avoid a potential bypass occlusion which is associated with secondary procedures. For ruptured AVMs, when patients presented with critical massive hematoma and brain shift, we conducted a combined approach in a single session.

    View this table:
    Table 1

    Details of procedures

    Transarterial embolization followed by surgical resection of a dural AVF (dAVF) was performed in a single session when the number of feeding arteries was limited and the surgical obliteration of superficial draining veins could be done simply. Burr hole opening and coil embolization of the isolated sinus was scheduled only when an endovascular access route was not feasible via a conventional transvenous approach for the treatment of the isolated dAVF.

    Results

    Sixteen patients underwent scheduled combined treatment and 13 patients had emergency combined procedures. Of these, three patients had a surgical procedure after an endovascular complication.

    Scheduled surgery

    Illustrative procedure 1: STA–MCA bypass

    Six patients underwent STA–MCA anastomosis followed by endovascular trapping of large or giant aneurysms (figure 1). Under general anesthesia, a 6F sheath was placed in the femoral artery before surgery and flushed with heparinized saline. The STA was carefully exposed using a surgical microscope, followed by craniotomy and STA–MCA microanastomosis. After skin closure, 3000 units of heparin were administered and a microcatheter was advanced to the level of the aneurysm. Using microballoon flow control, coil embolization of the aneurysm and its parent artery was performed. Postoperative 2D/3D angiography was performed to evaluate aneurysm obliteration and bypass patency. There were one major and two minor complications. One patient suffered cerebral infarction due to bypass occlusion. Two patients developed transient ischemic symptoms, speculatively considered as insufficient blood flow to the M1 perforators. Three patients were discharged without deficit.

    Figure 1
    Figure 1

    Superficial temporal artery–middle cerebral artery (STA–MCA) bypass followed by coil embolization for large aneurysm of the internal carotid artery. A patient who presented with diplopia and visual disturbance. (A) Cerebral angiogram showing a 15 mm large left ICA paraclinoid aneurysm. (B) A carbon head clamp was placed and STA–MCA bypass was performed microsurgically. (C,D) Post-bypass and embolization 2D/3D angiography demonstrated complete occlusion of the aneurysm with patency of the bypass.

    Illustrative procedure 2: dAVF/AVFs

    Three patients underwent transarterial embolization followed by surgical resection of dAVFs. Endovascular transarterial feeder occlusion was performed using embolic coils or N-butyl-cyanoacrylate (NBCA). Subsequently, a small craniotomy was made under intraoperative angiography guidance and the draining vein was obliterated with minimal bleeding.

    Five patients underwent direct puncture of the sinus or draining vein for endovascular occlusion of AVFs (figure 2). Under general anesthesia, a 5F sheath (either regular or kink-resistant) was placed in the femoral artery and a 5F diagnostic catheter was advanced to the common carotid artery to evaluate the angioarchitecture of the shunt. 5000 units of heparin were used to avoid thromboembolic complications. After diagnostic angiography, a small skin incision and a burr hole were made under fluoroscopic and roadmap guidance over the target shunt area and a 4F sheath was placed carefully in the sinus. A microcatheter was advanced into the distal portion of the fistula. Endovascular obliteration of the fistula point and origin of the draining cortical vein was achieved using detachable coils.

    Figure 2
    Figure 2

    Isolated transverse sigmoid dural arteriovenous fistula (dAVF). A patient presented with severe headaches and bruit. (A) Cerebral angiography revealed isolated left transverse sigmoid sinus dAVF draining into the cortical veins (Cognard type III). (B) A small skin incision and a burr hole were made on the sinus under fluoroscopic guidance. (C,D) Under 2D roadmap guidance, the microcatheter was advanced and superselective angiography was performed. The isolated sinus and draining veins were completely occluded with embolic coils (3D).

    Emergency surgery

    Illustrative procedure 3: ruptured AVM

    A patient presented with coma; conventional CT demonstrated massive intracranial hematoma (figure 3). The patient was immediately transferred to the hybrid endovascular OR. Cerebral angiography demonstrated a 5 cm diameter left temporoparietal AVM. Because of the complexity of the nidus morphology and being a midnight procedure, only hematoma evacuation and decompressive craniotomy were performed to rescue the patient. Three days after the initial hemorrhage the patient recovered from coma. The neurovascular team decided to perform combined embolization followed by surgical resection. Several feeding arteries and the nidus were embolized with 33% NBCA without heparinization. Subsequently, surgical resection of the AVM nidus was performed. Intraoperative angiography revealed complete resection of the nidus. The patient was discharged 1 month after treatment with a modified Rankin Scale score of 3.

    Figure 3
    Figure 3

    Ruptured arteriovenous malformation (AVM, Spetzler–Martin grade 5). A patient presented with coma. (A) Conventional CT demonstrated massive intracranial hematoma. (B) Cerebral angiography demonstrated a 5 cm diameter left temporoparietal AVM. (C) Embolization of the nidus with 33% N-butyl-cyanoacrylate. (D) Intraoperative angiography revealed complete resection of the nidus.

    Discussion

    The combined surgical and endovascular approach has become popular for the treatment of complex cerebrovascular diseases.1–7 ,11 ,12 Lawton et al reported a large series of combined microsurgical and endovascular treatments for complex and complicated vascular cases.3 In general, these combined treatment procedures were performed in the OR and angiosuite separately and the patients had to be transferred during the procedures. The endovascular OR environment has provided us with a wide array of new treatment options for complex cerebrovascular cases without moving the patients.

    Combined bypass and endovascular trapping for large complex aneurysms

    For complex large aneurysms, the standard technique has been bypass surgery followed by proximal surgical ligation or trapping. However, although the incidence is low, retrograde flow may maintain patency of the aneurysm and prohibit complete aneurysm occlusion by proximal ligation. Endovascular coil trapping has therefore become an effective technique, especially for large/giant internal carotid cavernous or paraclinoid aneurysms. Hacein-Bey et al reported their experience with combined operative and endovascular approaches for complex cerebral aneurysms.1 They concluded that such combined approaches promised the best possible outcomes. Shi et al reported a series of partially thrombosed giant MCA aneurysms treated with a combination of STA–MCA bypass and coil embolization.6 These procedures generally scheduled the bypass first and the coil trapping on the next day. However, bypass occlusion is a potential drawback of two-session combined treatment. Therefore, single-session combined treatment is a better option to avoid bypass occlusion.

    Ruptured AVM or aneurysm with hematoma

    In the case of a ruptured AVM, elective embolization followed by surgical resection of the AVM nidus is generally recommended. Emergency embolization and subsequent resection is relatively rare and should be applied only when intracranial pressure is critically high. In our six cases of combined treatment of AVMs, five presented with severe brain shift and deep-seated feeding arteries were embolized with NBCA. Overall, there were no technical complications and the immediate resection of the AVM allowed us more aggressive postoperative patient management. Most cases of ruptured aneurysm with hematoma could be treated by surgical hematoma evacuation and clipping. However, in the case of a large aneurysm, direct clipping is not always easy because of brain swelling after the hemorrhage. In such cases, immediate coil embolization followed by hematoma evacuation may be safer than conventional surgical clipping. Tawk et al reported their experience using a combined surgical and endovascular approach for ruptured aneurysms with hematoma with good results.11 They described the inconvenience of transporting patients from the endovascular suite to the OR and the importance of the hybrid OR. Postoperative C-arm CT (DynaCT, Siemens Medical Solutions, Erlangen, Germany) was also useful to confirm completeness of hematoma evacuation.

    Combined treatment for complex AVFs

    Combined surgical and endovascular approaches have been used for complex fistulas that were not amenable to conventional treatment. In the case of an isolated sinus with cortical venous drainage, endovascular navigation is impossible using a conventional transvenous approach. Pierot et al reported using a combined approach for the treatment of a complex superior sagittal sinus dAVF.5 Other authors also reported using a similar approach.12 ,13 They performed a burr hole opening in the OR and the patient was transferred to the angiosuite for endovascular occlusion. In the endovascular OR the precise burr hole opening was followed by direct microcatheter placement into the isolated sinus, which was easily conducted using modern 3D DSA technology. Recently, transarterial Onyx embolization enabled the complete cure of dAVFs.14 However, complete occlusion is not always guaranteed and sometimes catheter gluing is one of the complications of aggressive Onyx injection. Hallaert et al reported on the transarterial combined surgical and endovascular treatment of dAVF using Onyx.15 When the patient has a complex high-flow AV shunt, a scheduled transarterial feeder occlusion followed by surgical occlusion of the draining vein may be the best treatment option. In our two cases, subsequent surgical obliteration of the fistula was conducted without difficulty because of the immediate occlusion of feeders. Simultaneous treatment can minimize the risk of recruitment of new feeding arteries to the fistulas and reduce patient stress.

    Management of complications

    The incidence of aneurysm perforation during coil embolization ranges between 1% and 5%.16 ,17 Although it is rare, delay of surgical repair may result in an untoward outcome. Nussbaum et al reported on salvage surgery after endovascular complications.18 They pointed out the importance of the rapid reversal of anticoagulation and early surgical intervention.

    In the case of a ruptured internal carotid artery blistering aneurysm (so-called dorsal internal carotid artery aneurysm), direct clipping is sometimes challenging. Skrap et al reported on temporary balloon occlusion during the surgical treatment of giant paraclinoid and vertebrobasilar aneurysms.7 They had to move patients from the angiosuite to the OR after balloon placement. We used Hyperform (ev3, Irvine, California, USA) during the surgical procedure; once the craniotomy was made, we advanced the microcatheter under roadmapping guidance. The risk of thromboembolic complications may be low.

    Anticoagulation

    In general, heparinization is mandatory for endovascular procedures but contraindicated for open surgery. We did not use heparin during embolization of ruptured AVMs and there were no thromboembolic complications. For ruptured aneurysms, heparin was administered after the first coil placement and reversed before the surgical procedures. Postembolization hematoma evacuations and ventricular drainages were performed without postoperative hemorrhagic complications. We had earlier experienced an ischemic complication during a combined bypass and endovascular trapping. To avoid ischemic complications, preloading of antiplatelet drugs and intraoperative heparinization became our standard.

    Conclusion

    A combined endovascular and surgical approach conducted in a hybrid OR provides a new strategy for the treatment of complex neurovascular diseases.

    Acknowledgments

    The authors thank Dr Kostadin Karagiozov for manuscript preparation.

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    View Abstract

    Footnotes

    • Competing interests None.

    • Patient consent Obtained.

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