Recommended Technique for Spinal Angiography and Intervention

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This brief overview of techniques and intervention is not intended to replace standard textbooks in this field. Generally speaking, contrary to popular opinion, with modern catheter techniques in the hands of trained physicians, spinal diagnostic workup should have no complications higher than that of a diagnostic angiography of the peripheral vascular system. Infrequently, minor asymptomatic iliac or aortic dissections may be encountered in patients with significant arteriosclerosis.

Diagnostic angiography of the spine should be a focused study. Generally, MRI findings guide the invasive diagnostic workup. It is often pertinent to locate the artery of Adamkiewicz or radicularis magna as the major supply to the anterior spinal cord. However, if a vascular lesion, especially a dural arteriovenous malformation (fistula), is suspected, a more thorough angiogram may be required. This would include an angiogram of the aortic arch, the descending aorta, the abdominal aorta, and the pelvic system, and in the case of a cervical spinal cord malformation, the vertebral arteries, the thyrocervical trunk, and the deep and ascending cervical arteries. More recent magnetic resonance angiographic (MRA) studies have shown improved sensitivity in depicting dural AVFs and defining the level of the blood supply.43 This will help to focus the time needed for angiography.

An aortogram can be accomplished best by using a 5-Fr pigtail-configured catheter and a standard amount of contrast material (30-40 mL), which is injected over 2 seconds by means of a high-pressure pump. This helps occasionally in finding the level of the feeding arteries of the expected vascular lesion and may serve as a map for the selective spinal angiography, especially in patients with several missing intercostal or lumbar arteries. However, the disadvantage is that a large amount of contrast material is required for the study, thus, especially in patients with impaired renal function, it may be necessary to stop the procedure prematurely, and complete it the following day. The recent development of nonionic isomolar contrast agents (Visipaque, Iodixanol; Nycomed, Inc., Princeton, NJ) may be helpful because larger amounts can be used.

Figure 16.6. Continued. (F) Vertebral artery angiogram (frontal plane) prior to superselective catheterization demonstrates the dilated and tortuous radicular and somatic branches (arrows) and the patchy collection of contrast material in the lateral aspect of the vertebral body. (G) Superselective microcatheter injections of the lower radicular artery (arrow) prior to PVA embolization shows the contrast-filled "lakes" filling within the lateral aspects of the vertebral body. (H) A 5-Fr catheter has been placed into the ascending cervical branch of the thyrocervical trunk (open arrow). The microcatheter is placed through the guide catheter into the radicular artery anastomosis feeding the ABC prior to PVA embolization (arrow). (I) Control angiogram through the vertebral artery after embolization shows nearly complete devascularization. Note that the mi-crocatheter tip is still within the radicular artery (arrow). The mild vasospasm of the vertebral artery noted distal to the second radicular artery origin occurred after a balloon test occlusion.

Vertebral Artery Occlusion Test

Figure 16.7. Pelvic images of a 50-year-old female who presented with lower back pain and sensory deficit associated with a recurrent giant cell cancer of the sacrum. A preoperative PVA embolization was performed to reduce the intraoperative blood loss. (A) Contrast-enhanced T1-weighted image shows the patchy and irregular enhancement of the sacral body and epidural space (arrows). The nerve roots are encased in the tumor tissue. (B) Pelvic angiogram shows the tumor blood supply from both internal iliac artery branches and the median sacral artery.

Figure 16.7. Pelvic images of a 50-year-old female who presented with lower back pain and sensory deficit associated with a recurrent giant cell cancer of the sacrum. A preoperative PVA embolization was performed to reduce the intraoperative blood loss. (A) Contrast-enhanced T1-weighted image shows the patchy and irregular enhancement of the sacral body and epidural space (arrows). The nerve roots are encased in the tumor tissue. (B) Pelvic angiogram shows the tumor blood supply from both internal iliac artery branches and the median sacral artery.

Figure 16.7. Continued. (C) Super-selective microcatheterization of the right lateral sacral artery (arrow) prior to PVA embolization shows the diffuse tumor blush. (D) Superselective catheterization of the median sacral artery (arrow) prior to embolization shows the significant tumor blood supply through small anterior somatic branches.

Figure 16.7. Continued. (C) Super-selective microcatheterization of the right lateral sacral artery (arrow) prior to PVA embolization shows the diffuse tumor blush. (D) Superselective catheterization of the median sacral artery (arrow) prior to embolization shows the significant tumor blood supply through small anterior somatic branches.

Lateral Sacral Branch
d

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