P30. A single-position surgery with transpopliteal intraoperative angiography for complex spinal arteriovenous lesions: a case series

Abstract

BACKGROUND CONTEXT

Spinal arteriovenous lesions, including arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs), are rare but complex vascular anomalies. Certain subtypes, such as extradural AVMs with intradural drainage or dural AVFs resistant to endovascular treatment, pose significant diagnostic and therapeutic challenges.

PURPOSE

Intraoperative angiography via a transfemoral approach is useful for real-time lesion evaluation but requires patient repositioning, which can be inefficient. This study examines the feasibility of a single-position surgical approach incorporating transpopliteal intraoperative angiography for managing complex spinal arteriovenous lesions.

STUDY DESIGN/SETTING

Patients underwent laminectomy for decompression, with optional fixation, followed by lesion obliteration under transpopliteal intraoperative angiography and intraoperative neurophysiological monitoring (IONM). All procedures were performed in the prone position, with the popliteal area prepped for vascular access. A diagnostic catheter was introduced through the left popliteal artery for real-time intraoperative imaging.

PATIENT SAMPLE

Case 1: 48-year-old male presented with progressive bilateral lower limb numbness and urinary retention. MRI identified a vascular lesion at the left T9 level. Transpopliteal intraoperative angiography confirmed an AVM at the left T9-T10 intervertebral foramen, fed by the left 9th radicular artery with intradural venous drainage. Surgical excision was performed under IONM and with the assistance of transpopliteal intraoperative angiography. Case 2: 71-year-old female presented with acute bilateral lower limb weakness and numbness (muscle power 2/5). MRI revealed serpentine intradural vessels and dorsal spinal cord compression at the T8-T11 level. Spinal angiography confirmed a spinal dural AVF with a feeder from the right 8th thoracic segmental artery. The patient underwent lesion removal and spinal cord decompression under the same protocol. Case 3: 53-year-old female reported intermittent left lower limb weakness that had recently worsened. MRI showed serpentine intradural vessels, spinal cord edema, and intradural extramedullary flow voids at T11-L1. Spinal angiography confirmed a spinal dural AVF at the left L1 lumbar artery with engorged perimedullary veins. An attempted endovascular obliteration was deemed unfeasible due to poor accessibility and high risk. The patient underwent T12 and L1 laminectomy for decompression and AVF obliteration under the same protocol.

OUTCOME MEASURES

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METHODS

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RESULTS

All three patients demonstrated preserved or improved neurophysiological signals intraoperatively. Transpopliteal intraoperative angiography played a crucial role in lesion localization before durotomy. After obliteration, real-time angiography confirmed adequate flow in the distal cord-supplying arteries and the absence of residual lesions. Postoperative MRI and DSA confirmed complete lesion removal and resolution of serpentine intradural vessels. Spinal cord edema showed regression in all cases. Cases 1 and 3 reported persistent mild numbness, but case 1 experienced complete resolution of urinary retention, while lower limb weakness in cases 2 and 3 showed near-total improvement.

CONCLUSIONS

This study highlights the complexity of managing spinal arteriovenous lesions. The single-position surgical approach integrating transpopliteal intraoperative angiography provided multiple intraoperative benefits, including enhanced lesion localization and real-time flow assessment, while avoiding the challenges of transfemoral access in the prone position. Meticulous surgical planning and advanced intraoperative monitoring techniques are crucial for optimizing outcomes in complex spinal vascular surgeries.

FDA Device/Drug Status

This abstract does not discuss or include any applicable devices or drugs.