Combined Endovascular and Microsurgical Treatment of Arteriovenous Malformations in the Hybrid Operating Room.

Background and Purpose: This study sought to identify the efficacy and intraoperative operational details of single-stage combined embolization and microsurgery strategy for Spetzler-Martin (SM) grade III/IV/V arteriovenous malformations (AVMs). Methods: The authors retrospectively reviewed consecutive SM grade III/IV/V AVMs who underwent hybrid procedures and surgical resection alone procedures from January 2016 to February 2018. Outcomes [modified Rankin Scale (mRS)] were compared between hybrid group and surgical resection alone group in ruptured or unruptured subgroup. Factors associated with long-term disability were assessed using multivariable logistic regression analyses. Results: A total of 100 AVM patients (47 corrected using hybrid procedures whereas 53 by surgical resection alone) were evaluated. After a mean follow-up of 2.3 ± 0.6 years, we found no difference in long-term prognosis and incidences of disability rates between these two strategies. However, the hybrid strategy offers significant advantage in accelerating the resection process [ruptured (P = 0.000); unruptured (P = 0.002)]. In the analysis of risk factors, excessive embolization (Grade C, 60-100%) was significantly associated with long-term disability in the hybrid cohorts (P = 0.041; odds ratio, 24.000; 95% CI, 1.140-505.194), and involvement of deep perforating arteries was the significant predictor of long-term disability in the surgical resection alone cohort (P = 0.025; odds ratio, 15.389; 95% CI, 1.412-167.66). In the subgroup analysis of the hybrid cohort, moderate embolization (Grade B, 30-60%) was recommended because of the low risk ratio of major intraoperative bleeding (P = 0.033). Conclusions: Single-stage combined embolization and resection is an efficient strategy for the treatment of SM grade III/IV/V AVMs. Although the long-term outcomes were similar to surgical resection alone, the hybrid strategy had obvious advantages of shorter resection. In the hybrid technique, moderate embolization was recommended, and excessive embolization might be detrimental to the subsequent microsurgical resection. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT04136860.

/pdf/single-stage-combined-embolization-and-resection-for-2715q3xh9o.pdf

Single-Stage Combined Embolization and Resection for Spetzler-Martin Grade III/IV/V Arteriovenous Malformations: A Single-Center Experience and Literature Review.

Brain arteriovenous malformations (AVMs) near/within eloquent areas are challenging to treat surgically. The insufficient lesion-to-eloquence distance (LED) is related to poor neurological outcomes. This paper reports the use of in situ embolization combined with surgical resection in a one-staged hybrid operation for eloquent area protection. Nine patients who underwent one-staged in situ embolization combined with surgical resection were selected from the database of a prospective clinical trial (NCT03774017). Nidus got partial in situ embolization in the parts located near/within the eloquence. The rest of nidus was removed via a microsurgical procedure in the same operation. The in situ embolization ensured a sufficient LED to prevent eloquent areas and tracts from being damaged in the subsequent resection. All of the patients achieved complete obliteration with no neurological deficits or complications. One-staged hybrid operation initiates closer cooperation between surgical and endovascular treatments and proposes an integrative therapeutic mode for AVMs. The in situ embolization combined with surgical resection is safe and effective for improving the functional outcome of AVMs with eloquence and tracts involved. The clinical trial is registered at ClinicalTrials.gov (NCT03774017, https://clinicaltrials.gov/ct2/show/NCT03774017 ).

One-staged in situ embolization combined with surgical resection for eloquence protection of AVM: technical note.

https://journals.sagepub.com/doi/pdf/10.1177/0963689719845366

Combined Microsurgery and Endovascular Intervention in One-Stop for Treatment of Cerebral Arteriovenous Malformation: The Efficacy of a Hybrid Operation:

The primitive trigeminal artery (PTA), an abnormal carotid-basilar anastomosis, forms the vascular anomaly connection between the internal carotid artery and vertebrobasilar system. Rarely, PTA can be complicated by several other cerebrovascular disease, including arteriovenous malformations (AVMs), intracranial aneurysms, moyamoya disease, and carotid-cavernous malformations. Herein, we reported a rare case of PTA combined with an AVM in a male patient. The patient was a 28-year-old male with epileptic seizures at the onset of symptoms. Magnetic resonance imaging showed abnormal signal foci and localized softening foci formation with gliosis in the right parietal temporal lobe. Furthermore, using a digital subtraction angiogram (DSA), it was found that an abnormal carotid-basilar anastomosis had developed through a PTA originating from the cavernous portion of the right internal carotid artery (ICA) and a large AVM on the surface of the right carotid artery. The lesion of AVM tightly developed and draining into superior sagittal sinus. A hybrid operating room was used for the surgery. The main feeding arteries of the AVM originating from three major arteries, including the right middle cerebral artery, the right anterior cerebral artery, and the right posterior cerebral artery, were clipped and subsequently, then the AVM was thoroughly removed. The intraoperative DSA showed that the AVM had been resected completely. Postoperative pathological examination of the resected specimen indicated the presence of an AVM. The patient recovered well after surgery and has been symptom-free for more than 3 months. In summary, the pathogenesis of the coexistence of PTA and AVM remains unknown. As highlighted in this case report, hybrid surgery can be used to remove AVMs and can improve the patients' prognosis. To our best knowledge, this is the first case in the literature of successful AVM treatment using hybrid surgery.

Hybrid surgery for coexistence of cerebral arteriovenous malformation and primitive trigeminal artery: A case report and literature review

Objective
To summarize the clinical experiences of microsurgical and endovascular treatments of complicated arteriovenous malformation (AVM) in the conditions of hybrid operating room.


Methods
The clinical data were collected and analyzed for 8 patients of complex AVM between June 2012 to June 2013. There were Spetzler grade Ⅲ (n=2) and grade Ⅳ(n=6). And the lesions were complicated with intracranial aneurysms (n=3) and located in motor area (n=2) and basal ganglia (n=2). Five cases of AVM with cerebral hemorrhage underwent emergency surgery, including digital subtraction angiography (DSA) plus intraoperative embolization plus surgical resection of AVM plus intraoperative DSA (iDSA). Two cases underwent embolization plus aneurysm surgery while another had AVM embolization plus AVM resection and γ knife treatment.


Results
All surgical procedures, including iDSA, were completed in the same hybrid operating room. There was no change of surgical position or intraoperative mortality. Five patients of AVM hemorrhage undergoing emergency hematoma evacuation had no residue of AVM on iDSA. Their postoperative consciousness improved without neurological dysfunction. Two patients of limb paralysis recovered to paresis at 3 months postoperation. One case with blurry vision improved somewhat. Two cases undergoing elective surgery had a complete resection of AVM after embolization.


Conclusion
Surgery plus endovascular treatment in hybrid operating room is efficacious for complex cerebral AVM. It avoids multiple surgeries and inspections. And any lesion residue may be assessed immediately with postoperative DSA.


Key words: 
Arteriovenous malformation; Embolization; Microsurgery; Hybrid operation

Tian Jianping

Papers

Combined surgical and endovascular treatments of complex cerebral arteriovenous malformation in hybrid operating room