The value of intraoperative angiography in the time of indocyanine green videoangiography in the treatment of cerebrovascular lesions: Efficacy, workflow, risk-benefit and cost analysis A prospective study

Gregor Durner; Hellen Wahler; Michael Braun; Thomas Kapapa; Christian Rainer Wirtz; Ralph König; Andrej Pala

doi:10.1016/j.clineuro.2021.106628

The value of intraoperative angiography in the time of indocyanine green videoangiography in the treatment of cerebrovascular lesions: Efficacy, workflow, risk-benefit and cost analysis A prospective study

Clin Neurol Neurosurg. 2021 Apr 2:205:106628. doi: 10.1016/j.clineuro.2021.106628. Online ahead of print.

Authors

Gregor Durner¹, Hellen Wahler², Michael Braun³, Thomas Kapapa², Christian Rainer Wirtz², Ralph König², Andrej Pala²

Affiliations

¹ University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany. Electronic address: gregor.durner@bkh-guenzburg.de.
² University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany.
³ University of Ulm, Department of Neuroradiology, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany.

PMID: 33895619
DOI: 10.1016/j.clineuro.2021.106628

Abstract

Introduction: Intraoperative digital subtraction angiography (ioDSA) allows early treatment evaluation after neurovascular procedures. However, the value and efficiency of this procedure has been discussed controversially. We have evaluated the additional value of hybrid operating room equipped with an Artis Zeego robotic c-arm regarding cost, efficiency and workflow. Furthermore, we have performed a risk-benefit analysis and compared it with indocyanine green (ICG) angiography.

Methods: For 3 consecutive years, we examined all neurovascular patients, treated in the hybrid operating theater in a risk-benefit analysis. After using microdoppler and ICG angiography for best operative result, every patient received an additional ioDSA to look for remnants or unfavorable clip placement which might lead to a change of operating strategy or results. Furthermore, a workflow-analysis reviewing operating steps, staff positioning, costs, technical errors or complications were conducted on randomly selected cases.

Results: 54 patients were enrolled in the risk-benefit analysis, 22 in the workflow analysis. The average duration of a cerebrovascular operation was 4 h 58 min 2 min 35 s accounted for ICG angiography, 46 min 4 s for ioDSA. Adverse events occurred during one ioDSA. In risk-benefit analysis, ioDSA was able to detect a perfusion rest in 2 out of 43 cases (4,7%) of aneurysm surgery, which could not have been visualized by ICG angiography before. In arterio-venous-malformation (AVM) surgery, one of 11 examined patients (7,7%) showed a remnant in ioDSA and resulted in additional resection. The average cost of an ioDSA in Ulm University can be estimated with 1928,00€.

Conclusion: According to our results ioDSA associated complications are low. Relevant findings in ioDSA can potentially avoid additional intervention, however, due to the high costs and lower availability, the main advantage might lie in the treatment of selected patients with complexes neurovascular pathologies since ICG angiography is equally safe but associated with lower costs and better availability.

Keywords: Indocyanine green angiography; Intraoperative angiography; Workflow analysis.