Volume 169, January 2023, Pages 1-8Objective

Intraoperative spinal angiography via the popliteal artery for patients in the prone position has been reported only twice in 4 patients. This study aimed to clarify the safety precautions to be taken with this technique in a larger patient cohort.

Methods

Seven patients with spinal vascular disorders underwent intraoperative spinal angiography in the prone position via the popliteal artery. Ultrasound was used to evaluate the neurovascular anatomy in the popliteal fossa and guide the arterial puncture. Patient characteristics, features of angiography devices, puncture attempts, and angiography-related complications, such as hematoma formation and injury to the neurovascular bundle, were analyzed.

Results

The average number of arterial puncture attempts was 1.3 times (range: 1–2). Sheaths (4 and 4.5 Fr) with different ineffective lengths were used. In 1 case, a 4.5-Fr sheath was replaced with a 4-Fr sheath with a shorter noneffective length as the length of the catheter limited access to the target. Catheters with Type-JB2 tip shapes were used for craniocervical junction lesions, and those with Type-KAGAWA tip shapes were used for thoracic and lumbar spinal lesions. No puncture site complications were observed in any patient.

Conclusions

Intraoperative spinal angiography via the popliteal artery was an effective tool in surgeries for spinal vascular diseases. The introduction of the ultrasound enabled atraumatic puncture of the popliteal artery. Spinal targets above T5 to T6 may be inaccessible from the popliteal fossa when using a 100-cm-long catheter.

Introduction

Intraoperative digital subtraction angiography has been applied in intracranial vascular diseases, such as aneurysms,1 dural arteriovenous fistulas (dAVFs),2 and arteriovenous malformations.3 This technique has also been applied in spinal vascular lesions, such as dAVFs4,5 and epidural arteriovenous fistulas (AVFs).6 Generally, femoral artery puncture is the first choice for patients in the supine position. However, for spine surgery with the patient in the prone position, transfemoral angiography has potential risks of kinking and blood clotting in the sheath or catheter and contamination of the access site.7 A transpopliteal approach was initially applied in peripheral arterial lesions.8, 9, 10 In 2018, Villelli et al.11 were the first to report the application of this approach in intraoperative spinal angiography for 3 patients with dAVFs and tumors. Then, there was a single-case report of this technique being applied in the treatment of spinal hemangioma.12 In the present study, data on patients who underwent transpopliteal intraoperative spinal angiographies were reviewed to clarify the safety and precautions of this technique.

Section snippetsMethods

Between October 2018 and October 2021, 7 patients underwent intraoperative spinal angiography via the popliteal artery in the prone position. We retrospectively reviewed these cases to examine the safety and precautions of this technique. Data on patient characteristics, location and diagnosis of the lesion, diameter of the popliteal artery, time and number of puncture attempts, features of the sheath and catheter used for the procedure, and angiography-related complications (which included

Results

Table 1 summarizes the characteristics of the patients, sheaths, and angiocatheters used, including the number of arterial puncture attempts and angiography-related complications.

Six of the 7 patients were men. Five patients were diagnosed with dAVF; 1, perimedullary AVF; and 1, epidural extradural AVF. Regarding the spinal location of the lesions, 3 were located at the craniocervical junction (CCJ), 2 at the thoracic spine, 1 at the lumbar spine, and 1 at the filum terminale. Surgical

Intraoperative Spinal Angiography Considerations for Patients in the Prone Position

This study demonstrated that transpopliteal spinal angiography is a feasible imaging modality for spine surgery when the patient is in the prone position. This technique covered all lesions from the CCJ to the lumbar spine without any complications. Important points noted from the experience were as follows: (1) the transpopliteal approach can eliminate catheter-related problems observed with the transfemoral approach, such as kinking, blood clotting, and access site contamination; (2)

Conclusions

This study provides practical information on transpopliteal spinal angiographies in challenging surgeries for spinal vascular lesions. It reveals how artery puncture can be performed more efficiently and safely under ultrasonographic guidance. If issues related to the distance to the target and length of the sheath and catheter are considered, this technique can be a useful modality in surgeries for spinal vascular lesions.

CRediT AUTHORSHIP CONTRIBUTION STATEMENT

Yuyo Maeda contributed to the design of the study, data analysis, and interpretation of the results and writing the manuscript. Takafumi Mitsuhara contributed to the design of the study and interpretation of the results. Yuyo Maeda, Takafumi Mitsuhara, Shinji Kume, Shigeyuki Sakamoto, Kiyoharu Shimizu, Jumpei Oshita, Yousuke Kajihara and Masaaki Takeda contributed to the acquisition of and maintaining the data. Popliteal artery puncture was performed by Yuyo Maeda and Shigeyuki Sakamoto.

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