Femoral Artery Approach Using a Long Guiding Sheath in Intraoperative Angiography

Background and Purpose: Intraoperative angiography (IOA) and intraoperative interventional radiology (IO-IVR) are useful for surgical correction of neurovascular pathologies, such as dural arteriovenous fistula (DAVF), cerebral arteriovenous malformation (AVM), and spinal AVM. The development of a hybrid operating room allows evaluation and treatment with increased precision. Further, opportunities for simultaneous treatment of direct and intravascular surgeries are increasing, even without the use of hybrid operating rooms. However, the traditional femoral approach involves poor sterility at the access site, which may prove problematic during extended surgeries. In this study, we devised a method to enable effective IOA and IO-IVR in any surgical position with a long guiding sheath.Methods: Twenty-three patients (male:female=11:12; age, 17-73 years; mean, 49.0) who underwent IOA between April 2011 and April 2018 were included in the study. In each patient, the right femoral artery was punctured, and IOA was performed using a long guiding sheath. Then, patient positioning was maintained to ensure a sterile catheter system.Results: Twenty-three patients underwent surgeries: AVM, 11 (47.8%); DAVF, six (26.1%); aneurysm, three (13%); tumor, two (8.6%); and arteriovenous injury, one (4.3%). Surgeries were performed in the supine position for 13 patients (56.5%), prone position for seven (30.4%), and park-bench position for three (13.0%). All supra-aortic vessels were catheterized with a success rate of 100%. In some cases, we easily exchanged catheters, even in the prone and park-bench positions, by using the C-arm. In one patient with AVM who developed cerebral infarction, we did not perform our usual procedure.Conclusions: A long guiding sheath allows performance of angiography in various positions. Our method is useful even without a hybrid operating room.