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Hybrid cerebrovascular surgeon

Because the fields of microvascular and endovascular surgeries are both technically complex, there has been concern that hybrid cerebrovascular surgeons cannot perform each technique with the skill necessary to achieve good outcomes. When compared to clipping and coiling reviews in the neurosurgical literature, we illustrate that one hybrid neurovascular surgeon is capable of attaining great facility in both techniques and that this type of physician will represent one practice model of cerebrovascular specialist in the future. This has potential implications for the training of hybrid cerebrovascular surgeons 1)

A study evaluated the outcomes of coiling versus clipping of unruptured anterior communicating artery aneurysms (A-com) treated by a hybrid vascular neurosurgeon to suggest the best protocol of management for these conditions.

They retrospectively reviewed the records of 70 patients with an unruptured A-com aneurysm treated with coiling or clipping performed by a hybrid vascular neurosurgeon between March 2012 and December 2019. The patients were dichotomized, into the coil group or clip group. Treatment-related complications, clinical and radiological results were evaluated.

Of the 70 patients identified, 37 underwent coiling and 33 clipping. Procedure-related symptomatic complications occurred in 2 patients (5.4%) in the coil group and 3 patients (9.1%) in the clip group. Poor clinical outcome (modified Rankin Scale [mRS] of 3 to 6) at 6 months of follow-up was seen in only one patient (2.7%) for the coil group, and none for the clip group. The one poor outcome was the result of intra-procedural rupture during coiling. Follow-up conventional angiography data (mean duration, 15.0 months) revealed that the major recanalization rate is 5.6% for the coil group and 10.0% for the clip group.

Management of A-com aneurysms requires more collaboration between microsurgical clipping and endovascular therapy. Evaluation of patient and aneurysm characteristics by considering the advantages and disadvantages of both techniques could provide an optimal treatment modality. A hybrid vascular neurosurgeon is expected to be a proper solution for the management of these conditions 2).

Since June 2013 a hybrid operation theatre is used interdisciplinary in the department for surgery of Ulm University. In this operation theatre a floor-based flat panel c-arm, which is mounted on a robotic arm that can be controlled by the surgeon in a sterile environment, is linked to the operating table. Furthermore for the first time it was possible to integrate a navigation system in this setting. The interdisciplinary utilization (trauma, neurosurgery, cardiac and vascular surgery) makes this hybrid operation theatre very time and cost effective. In the orthopedic trauma department this system is mainly used for traumatic and oncologic pelvic and spinal injuries. In these anatomical regions the excellent image quality and large field of view of the robotic flat panel detector based 3D imaging combined with an intraoperative navigation system is a huge advantage. The system can also be used for complex fractures of the extremities. In the future there will be an integration of further imaging modalities and referenced holding devices in this setting 3).

The ability of our cerebrovascular surgeons to perform minimally-invasive, image-guided procedures has been enhanced by the construction in 2011 of NYU Langone’s state-of-the-art “hybrid” operating room. This new OR of the future combines the facilities of a standard operating room with the technology of a digital flat-panel interventional neuroradiology suite, including built-in X-ray imaging, computer guidance systems, and video-integrated technology that projects and records 3-D images of the surgical field onto high-definition plasma monitors. In addition to being ideal for minimally-invasive cerebrovascular procedures, the OR’s multiple capabilities also allow our surgeons to customize neurosurgical procedures for each individual patient, utilizing both minimally-invasive and open microsurgery as needed.

The direct interaction between neurosurgeons and neuroradiologists in a joint environment changes and accelerates all diagnostic and therapeutic steps because all relevant procedures, including treatment control can be performed in a single room. Interventions of the skull base or the spine are also a domain of such hybrid theatre.

As this new concept requires organisational changes throughout the entire patient management, a change of mindset is also needed at the institutional level in order to attain maximum benefits from such a setting 4).

The cases of CAVMs treated in Qilu hospital and People's Hospital of Xinjiang Uygur Autonomous Region from July 2011 to July 2016 were analyzed retrospectively.Two modes of hybrid surgery, “angiographic diagnosis-craniotomy lesion resection or/and hematoma clearance-intraoperative angiography evaluation” and “angiographic diagnosis-intraoperative embolization-craniotomy lesion resection or/and hematoma clearance-intraoperative angiography evaluation” were applied for all the cases.We placed an aneurysm clip as marker in surgery field during real-time angiography.If CAVMs residues occurred during surgery, we re-resected the residue according to the guidance of the marker (clip) and DSA imaging. Intra-operative angiography evaluated the results of CAVMs resection one more time.Postoperatively, follow-up CT scan was performed for all the patients. Results: Of all the cases with CAVMs, there were 8 cases of scale Ⅰ, 13 cases of scale Ⅱ, 10 cases of scale Ⅲ and 6 cases of scale Ⅳ according to Spetzler-Martin Scale.There were 28 cases of acute hemorrhagic CAVMs and 9 cases of chronic hemorrhagic CAVMs or no-hemorrhagic CAVMs.Intra-operative angiography showed CAVMs residues in 6 cases of acute hemorrhagic CAVMs and only one in chronic group.About 18.92% residual rate of CAVMs were found for the first time intra-operative assessment angiography.With the guidance of intra-operative angiography and aneurysm clip as Marker, all residues of CAVMs were resected totally.Follow up CT showed the hematomas disappeared in all the cases of acute hemorrhagic cases.The cure rate of CAVMs with hybrid surgery was 100% according to the final intra-operative assessment angiography.

(1)Hybrid surgery for the treatment of CAVMs in one session could evaluate the results of CAVMs resection and instruct the surgical procedure according to real-time angiography.This model could improve the treatment safety and efficacy for patients with CAVMs.(2)Patients with higher Spetzler-Martin Scale (Ⅲ-Ⅳ) who need intra-operative embolization and patients with hemorrhagic CAVMs are more suitable for hybrid surgery 5).

Alexander BL, Riina HA. The combined approach to intracranial aneurysm treatment. Surg Neurol. 2009 Dec;72(6):596-606; discussion 606. doi: 10.1016/j.surneu.2009.06.027. Epub 2009 Oct 9. PMID: 19818994.
Moon JS, Choi CH, Lee TH, Ko JK. Result of coiling versus clipping of unruptured anterior communicating artery aneurysms treated by a hybrid vascular neurosurgeon. J Cerebrovasc Endovasc Neurosurg. 2020 Oct 6. doi: 10.7461/jcen.2020.E2020.06.005. Epub ahead of print. PMID: 33017881.
Richter PH, Gebhard F. [The interdisciplinary hybrid operation theatre. Current experience and future]. Chirurg. 2013 Dec;84(12):1036-40. doi:10.1007/s00104-013-2558-0. German. PubMed PMID: 24220954.
Schaller K, Cabrilo I, Pereira VM, Bijlenga P. [Hybrid operation theatre from the perspective of neurosurgery]. Chirurg. 2013 Dec;84(12):1041-7. doi:10.1007/s00104-013-2555-3. German. PubMed PMID: 24218082.
Wu HX, Paerhati R, Feng GJ, Yang XP, Zhao P, Liu QL, Li G, Li XG, Wang DH. [Clinical application of hybrid surgery for the treatment of cerebral arteriovenous malformations]. Zhonghua Yi Xue Za Zhi. 2017 Mar 21;97(11):817-821. doi: 10.3760/cma.j.issn.0376-2491.2017.11.005. Chinese. PubMed PMID: 28355735.
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