Transoral Robotic Surgery-Assisted Removal of Upper Aerodigestive Tract Foreign Bodies with Intraoperative Localization.

OBJECTIVE: To describe the use of transoral robotic surgery (TORS) in conjunction with intraoperative localization techniques for removal of challenging upper aerodigestive tract (UADT) foreign bodies. METHODS: Three cases were taken to the operating room for removal of UADT foreign bodies. Two of these cases had previously undergone failed surgery(s). TORS was performed in all 3 cases and intraoperative localization was used in 2 cases. RESULTS: All foreign bodies were successfully removed. CONCLUSION: This case series is the largest-to-date on UADT foreign body removals using TORS. Additionally, the novel use of intraoperative localization techniques in conjunction with TORS is described. Such an approach can facilitate the identification of difficult-to-identify foreign bodies, as well as potentially decreasing operative time, number of operations, and associated morbidity.

Intraoperative radio-guided localization of parathyroid adenomas using 3D freehand SPECT technology.

Parathyroidectomy for primary hyperparathyroidism (PHPT) could have poor outcomes, even with accurate preoperative localization of the adenomas, because their intraoperative localization can be challenging. Freehand single photon emission computed tomography (fhSPECT) is a new technique for radio-guided intraoperative navigation. Its use during parathyroidectomy could be useful and such data are limited. We herein present our experience on the feasibility of fhSPECT for intraoperative detection of abnormal parathyroid glands. We retrospectively reviewed the clinical data of 55 patients (30-77 years old) with PHPT due to parathyroid adenomas, that were subjected to parathyroidectomy from 12/2017 to 7/2022. In average, 111 ± 74 MBq of Tc-99 m Sestamibi were injected intravenously, approximately 2 h before the operation and fhSPECT was used to generate 3D images during parathyroidectomy. Measurements of PTH and calcium levels were performed preoperatively, postoperatively and 4-6 months after the procedure. FhSPECT successfully identified the parathyroid adenoma in all the patients. It took 3 min (median time) for fhSPECT to detect at least one radioactive spot in all patients. The mean duration of the operation was 66.6 ± 7.3 min. Forty-nine patients out of 55 had solitary and 6/55 had multiple adenomas, whereas 6/55 had ectopic abnormal parathyroid glands. None of the patients had persistent hyperparathyroidism during follow-up. To the best of our knowledge, this is the largest series of patients with PHPT that underwent fhSPECT assisted parathyroidectomy. Our data suggest that this navigation system is helpful in identifying parathyroid adenomas intraoperatively.

Radioactive Seed Localization for Nonpalpable Breast Lesions: Systematic Review and Meta-Analysis.

BACKGROUND: This study is a systematic review with meta-analysis comparing radioactive seed localization (RSL) versus radio-guided occult lesion localization (ROLL) and wire-guided localization (WGL) for patients with impalpable breast cancer undergoing breast-conserving surgery and evaluating efficacy, safety, and logistical outcomes. The protocol is registered in PROSPERO with the number CRD42022299726. METHODS: A search was conducted in the Embase, Lilacs, Pubmed, Scielo, Web of Science, and clinicaltrials.gov databases, in addition to a manual search in the reference list of relevant articles, for randomized clinical trials and cohort studies. Studies selected were submitted to their own data extraction forms and risk of bias analysis according to the ROB 2 and ROBINS 1 tools. A meta-analysis was performed, considering the random effect model, calculating the relative risk or the mean difference for dichotomous or continuous data, respectively. The quality of the evidence generated was analyzed by outcome according to the GRADE tool. Overall, 46 articles met the inclusion criteria and were included in this systematic review; of these, 4 studies compared RSL and ROLL with a population of 1550 women, and 43 compared RSL and WGL with a population of 19,820 women. RESULTS: The results showed that RSL is a superior method to WGL in terms of surgical efficiency in the impalpable breast lesions' intraoperative localization, and it is at least equivalent to ROLL. Regarding security, RSL obtained results equivalent to the already established technique, the WGL. In addition to presenting promising results, RSL has been proven to be superior to WGL and ROLL technologies.

Onyx®, A New Tool for Intraoperative Localization of Liver Lesions.

BACKGROUND: Precise preoperative localization of liver tumors facilitates successful surgical procedures, Intraoperative ultrasonography is a sensitive imaging modality. However, the presence of small non-palpable isoechoic intraparenchymal lesions may be challenging intraoperatively. METHODOLOGY AND MATERIAL DESCRIPTION: Onyx® is a non-adhesive liquid agent comprised of ethylene-vinyl alcohol usually used dissolved in dimethyl-sulfoxide and suspended micronized tantalum powder to provide contrast for visualization under fluoroscopy and ultrasonography and a macroscopic black shape. This embolization material has been increasingly used for the embolization of intracranial arteriovenous malformations. We present the novel application of Onyx® on liver surgery. CURRENT STATUS: We present the case of a female, 55 years-old, whose medical history revealed an elective sigmoidectomy (pT3N1a). After 17 months of follow up, by PET-CT scan, the patient was diagnosed of a small intraparenchymal hypo-attenuated 13 mm tumor located at segment V consistent with metachronous colorectal liver metastasis. Open metastasectomy was performed, ultrasonography-guided Onyx® infusion was delivered the day after, intraoperative ultrasonography showed a palpable hyperechoic material with a posterior acoustic shadowing artifact around the lesion. Onyx® is a promising new tool, without any previous application on liver surgery, feasible with advantages in small not palpable intraparenchymal liver lesions.

Image-Guided VATS in the Hybrid Operation Room Facilitates Early Diagnosis and Concurrent Treatment of Subcentimeter Nonpalpable Lung Nodules.

OBJECTIVE: As lung cancer screening increases, the detection of small, nonpalpable lung lesions is on the rise. The hybrid operation room (OR), which combines percutaneous or endobronchial fiducial placement with on-table computed tomography (CT) and fluoroscopic guidance, improves localization and facilitates the diagnosis and treatment of smaller, nonpalpable lung nodules with greater accuracy. METHODS: In 35 consecutive months, 55 veterans underwent 60 image-guided video-assisted thoracic surgery procedures for lesion resection. Of the cases, 36% were found during lung cancer screening. All patients received their care in the hybrid OR, where cone-beam CT scan technology was used to place an average of 1.6 fiducials percutaneously (n = 55) or via augmented navigational bronchoscopy (n = 5). RESULTS: A total of 66 lesions were resected. The median lesion size was 8 mm with an interquartile range of 6 to 14. The patients underwent nonanatomical resection with lymph node dissection using radiologic guidance. When indicated, an anatomical resection was subsequently performed. Of 47 total non-small cell lung cancer lesions, 83% were diagnosed at stage IA1 or IA2. The median surgical margin was 15 mm; the margin was usually 1.5 times as wide as the lesion. CONCLUSIONS: The hybrid OR technology gives a 3-dimensional assessment of the small lung lesions, allowing for a tissue-saving resection while achieving good surgical margins. During lung cancer screening, smaller, nonpalpable lung nodules are frequently found. This technology allows resection of subcentimeter lesions, which would otherwise be unresectable at this early stage, possibly improving survival.

Two-stage minimally invasive pulmonary resections with intraoperative localization technique for bilateral multiple primary lung cancers: A case report.

Multiple primary lung cancers (MPLCs) are becoming more and more common and these patients can benefit from minimally invasive surgery. Here, we report a case of a patient diagnosed with synchronous MPLCs who underwent bilateral thoracoscopic pulmonary resections in a two-stage strategy, and achieved a good surgical outcome and high quality of life. A 66-year-old female was found to have one major ground-glass nodule (GGN) in the right upper lobe and eight minor GGNs in the left upper and lower lobes. The patient underwent right upper lobe resection and systematic mediastinal lymph node dissection via single-utility port thoracoscopic surgery in September 2018. Pathology was lepidic predominant adenocarcinoma pT1bN0M0, IA2. Regular high-resolution computed tomography examination during 36 months after right upper lobectomy showed gradually increasing diameter and solid component of multiple GGNs in left lung. The patient underwent thoracoscopic multiple pulmonary resections using an intraoperative localization technique in a hybrid operating room in October 2021 and all eight nodules in the left lung were resected. Two segmentectomies and four wedge resections were performed, and the pathological results of the eight nodules included four adenocarcinomas, three adenocarcinomas in situ, and one alveolar epithelial hyperplasia. The two operations were successful with no intra- or postoperative 90-day complications. During more than 20 months of follow-up after the second operation, the patient had well recovered pulmonary function and physical status with a Karnofsky performance status score of 90 and no local recurrence or metastasis. A two-stage surgical strategy for synchronous MPLCs is therefore feasible. The surgical strategy, timing of intervention, and extent of pulmonary resection should be individually designed according to the location and characteristics of each nodule. Intraoperative localization of small GGNs is very important to ensure that all nodules are completely and accurately resected during the operation.

Augmented reality navigation-guided intraoperative pulmonary nodule localization: a pilot study.

Background: With the increasing number of small pulmonary nodules detected, effective localization of pulmonary nodules has become an issue. The goal of this study is to determine the safety and feasibility of a newly developed augmented reality navigation technology for intraoperative localization of small pulmonary nodules. Methods: We conducted a prospective single-center feasibility study of a novel augmented reality navigation system and lung localization (LungBrella) marker on ten patients between July and October 2020. For augmented reality navigation-guided localization, a preoperative chest computed tomography scan was performed to generate 3-dimensional (3D) virtual images and individualized localization plan, which were uploaded into Hololens (a head-mounted augmented reality device). Under the guidance of established procedure plan displayed by HoloLens, localization marker was placed in operating room. Segmentectomy or wedge resection was subsequently performed. The primary endpoint was the localization procedure success rate, and the secondary endpoints were localization time, operation time, and complications. Results: Localization was successful in seven of the ten procedures. Due to different reasons, failures were noted in three cases, after which immediate adjustments were made. In the successful cases, the LungBrella marker was positioned at a median of 5.8 mm (range, 0-10 mm) from the edge of the nodule. Median localization time was 9.4 min (range, 5-19 min), and median operation time was 172.9 min (range, 105-200 min). There were no complications during the entire process. Conclusions: This exploratory study suggests that augmented reality navigation-guided pulmonary nodule localization is a safe and feasible technique (ClinicalTrials.gov identifier, NCT04211051).

The well-matched interaction between virtuality and reality for intraoperative localization of nonpalpable pulmonary nodules.

Background: The intraoperative localization of nonpalpable pulmonary nodules for thoracoscopic wedge resection is technically challenging. Current preoperative image-guided localization techniques require additional time, costs, procedural risks, advanced facilities, and well-trained operators. In this study, we explored a cost-effective method of well-matched interaction between virtuality and reality for accurate intraoperative localization. Methods: Through the integration of techniques involving preoperative 3-dimensional (3D) reconstruction, temporary clamping of target vessel and the modified inflation-deflation method, the segment on the 3D virtual model and the segment under the thoracoscopic monitor were well matched in the inflated state. Then the spatial relationships of target nodule to the virtual segment could be applied to the actual segment. The well-matched interaction between virtuality and reality would facilitate nodule localization. Results: A total of 53 nodules were successfully localized. The median maximum diameter of the nodules was 9.0 mm (interquartile range [IQR], 7.0-12.5 mm). The median depthmin and depthmax were 10.0 mm and 18.2 mm, respectively. The median macroscopic resection margin was 16 mm (IQR, 7.0-12.5 mm). The median duration of chest tube drainage was 27 hours, with a median total drainage of 170 mL. The median postoperative length of hospital stay was 2 days. Conclusions: The well-matched interaction between virtuality and reality is safe and feasible for intraoperative localization of nonpalpable pulmonary nodules. It may be proposed as a preferred alternative to traditional localization methods.

Three-dimensional printing template for intraoperative localization of pulmonary nodules in the pleural cavity.

Objectives: Localization of pulmonary nodules is challenging. However, traditional localization methods have high radiation doses and a high risk of complications. We developed a noninvasive 3-dimensional printing navigational template for intraoperative localization. It can reduce puncture-related complications and simplify the localization process. This study will verify the feasibility of this method. Methods: Patients with peripheral pulmonary nodules were included in this study. The computed tomography scan sequences were obtained to design a digital template model, which was then imported into a 3-dimensional printer to produce a physical navigational template. Finally, the navigational template is placed into the patient's pleural cavity for intraoperative localization. The precision of the nodule localization and associated complications were evaluated. Results: Twelve patients were finally included in this study. Intraoperative navigational template localization was used in all patients. The success rate of intraoperative nodule localization was 100%, and the median time of localization was 19.5 minutes (range, 16-23.5 minutes). The deviation median of the navigational template was 2.1 mm (range, 1.1-2.7 mm). Among the included patients, no significant complications occurred during intraoperative localization. Conclusions: The 3-dimensional printing template for intraoperative localization is feasible, will cause no trauma to the patient, and has acceptable accuracy for application in nodules localization. This navigational template greatly simplifies the localization process and may potentially break the dependence of percutaneous localization on computed tomography scanning.

Advances in Imaging to Aid Segmentectomy for Lung Cancer.

Pulmonary segmentectomy has become a widely accepted technique for resection of early-stage lung cancers. Intraoperative identification of small nodules within the lung parenchyma and definition of segmental anatomy are essential for oncologic segmental resection and significantly enhanced by recent advances in imaging techniques. Advances in imaging for nodule localization, using preoperative markers and three-dimensional computed tomography, delineation of segmental anatomy, and sentinel lymph node mapping have become important components of planning and performing minimally invasive anatomic segmentectomies and are particularly well suited for the evolving robotic-assisted platform.

Virtual navigation bronchoscopy-guided intraoperative indocyanine green localization in simultaneous surgery for multiple pulmonary nodules.

BACKGROUND: Accurate localization of pulmonary nodules is the main difficulty experienced in wedge resection. Commonly used localization methods have their own advantages and disadvantages. However, clinical work has demonstrated that intraoperative indocyanine green localization under electromagnetic navigation bronchoscopy/virtual navigation bronchoscopy (VNB) is more advantageous than conventional methods for patients with multiple pulmonary nodules undergoing simultaneous surgery, especially for those undergoing bilateral lung surgery. METHODS: Data of patients undergoing simultaneous surgery for multiple pulmonary nodules with preoperative methylene blue localization by computed tomography (CT)-guided percutaneous lung puncture (methylene blue group) or intraoperative indocyanine green localization under VNB (virtual navigation group) were retrospectively analyzed. Patient characteristics, pulmonary nodule features, localization time, preoperative location time, location success rate, operation time, complication incidence, visceral pleural staining rate after localization, and pulmonary nodule primary resection success rate were compared between the two groups. RESULTS: The methylene blue and virtual navigation groups comprised 39 and 20 patients with 119 and 67 pulmonary nodules resected, respectively. Sex, age, number of pulmonary nodules resected simultaneously, unilateral/bilateral lung surgery, pulmonary nodule size, distance between pulmonary nodules and the visceral pleura, pulmonary nodule consolidation-to-tumor ratio, location of pulmonary nodules in the pulmonary lobe, postoperative pathology, visceral pleura staining rate, primary pulmonary nodule resection success rate, and surgical duration did not differ significantly between the groups (p > 0.05). The localization time of the virtual navigation group was significantly shorter than that of the methylene blue group (p < 0.05), regardless of unilateral or bilateral multiple nodules. In the methylene blue group, 25.64% (10/39) of patients presented complications, all of which were pneumothorax, whereas no complications were found in the virtual navigation group. CONCLUSIONS: For patients with multiple pulmonary nodules undergoing simultaneous surgery, indocyanine green injection under VNB can achieve a similar effect on pulmonary nodule localization as classical methylene blue injection under CT-guided percutaneous lung puncture, with shorter localization time and fewer complications.

Autofluorescence of parathyroid glands during endocrine surgery with minimally invasive technique.

PURPOSE: Accidental injury to the parathyroid glands (PTGs) is common during thyroid and parathyroid surgery. To overcome the limitation of naked eye in identifying the PTGs, intraoperative autofluorescence imaging has been embraced by an increasing number of surgeons. The aim of our study was to describe the technique and assess its utility in clinical practice. METHODS: Near-infrared (NIR) autofluorescence imaging was carried out during open parathyroid and thyroid surgery in 25 patients (NIR group), while other 26 patients underwent traditional PTG detection based on naked eye alone (NO-NIR group). Primary variables assessed for correlation between traditional approach and autofluorescence were number of PTGs identified and incidence of postoperative hypoparathyroidism (hypoPT). RESULTS: 81.9% of PTGs were detected by means of fluorescence imaging and 74.5% with visual inspection alone, with an average of 2.72 PTGs visualized per patient using NIR imaging versus approximately 2.4 per patient using naked eye (p = 0.38). Considering only the more complex total thyroidectomies (TTs), the difference was almost statistically significant (p = 0.06). Although not statistically significant, the observed postoperative hypoPT rate was lower in the NIR group. CONCLUSION: Despite the limitations and technical aspects still to be investigated, fluorescence seems to reduce this complication rate by improving the intraoperative detection of the PTGs.

Pre- and intraoperative thoracic spine localization techniques: a systematic review.

OBJECTIVE: In the era of modern medicine with an armamentarium full of state-of-the art technologies at our disposal, the incidence of wrong-level spinal surgery remains problematic. In particular, the thoracic spine presents a challenge for accurate localization due partly to body habitus, anatomical variations, and radiographic artifact from the ribs and scapula. The present review aims to assess and describe thoracic spine localization techniques. METHODS: The authors performed a literature search using the PubMed database from 1990 to 2020, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 27 articles were included in this qualitative review. RESULTS: A number of pre- and intraoperative strategies have been devised and employed to facilitate correct-level localization. Some of the more well-described approaches include fiducial metallic markers (screw or gold), metallic coils, polymethylmethacrylate, methylene blue, marking wire, use of intraoperative neuronavigation, intraoperative localization techniques (including using a needle, temperature probe, fluoroscopy, MRI, and ultrasonography), and skin marking. CONCLUSIONS: While a number of techniques exist to accurately localize lesions in the thoracic spine, each has its advantages and disadvantages. Ultimately, the localization technique deployed by the spine surgeon will be patient-specific but often based on surgeon preference.

A safe, reliable, inexpensive and novel technique to localize in the mid thoracic spine in the prone position: Proof of concept and technical illustration.

Intraoperative localization within the thoracic spine in the prone position may be particularly difficult on account of absence of common landmarks such as the sacrum or the C2 vertebra, thus increasing the potential for wrong-level surgery that may lead to patient morbidity and potential litigation. Some current localization methods involve implantation of markers that are invasive and serve to add to procedural expense while yet still failing to entirely eliminate errors. We describe a novel, non-invasive, and inexpensive technique for intraoperative localization of the thoracic spine in the prone position using an esophageal temperature probe. Following patient positioning, anteroposterior fluoroscopy is used to localize the radiopaque tip of the esophageal probe relative to the thoracic spine. After determining the probe tip's location, it becomes the counting reference for all subsequent intraoperative fluoroscopic localizations during surgery. As the probe tip is generally visible in the same fluoroscopic image as the surgical level, error from parallax created when moving the fluoroscopy machine from an anatomic landmark either above or below is avoided and a shorter fluoroscopy time is needed. Use of an esophageal temperature probe as a landmark in localizing spinal level may serve as a reliable and It offers a safe, reliable, and inexpensive technique for proper localization of thoracic spine levels.

Image-localized body surface marking for the intraoperative localization of pulmonary ground-glass nodules.

BACKGROUND: The method of locating pulmonary nodules before operation plays a crucial role in the surgery of pulmonary ground-glass nodules (GGNs). However, the methodologies surrounding intraoperative localization remains limited, with the majority procedures requiring specific additional equipment. We report a new approach in locating pulmonary GGNs by image-localized body surface marking intraoperative (IBMI) localization. METHODS: A retrospective review of the medical records of 76 patients with pulmonary GGNs was performed. All patients underwent IBMI localization between January 2018 and March 2019. Twenty-six patients underwent CT-guided hook wire localization before IBMI localization during surgery. IBMI localization was undertaken directly without pre-treatment in the remaining patients. The efficacy and complications of this approach were analyzed and compared with other pre- or intraoperative localization methods in the current literature. RESULTS: The intraoperative localizations were performed successfully in 72 of all 76 patients pulmonary GGNs within a mean duration of 5.3±1.8 (range, 2.0 to 9.6) minutes. The GGNs in four cases were found to have a significant deviation (>1.5 cm) from the positioning points. All GGNs were successfully resected. Except for five cases of active chest wall bleeding (6.5%), no other intra- or postoperative complications occurred. CONCLUSIONS: The IBMI localization approach is a safe and short-duration procedure with high success rates and fewer complications. We used it for the first time for intraoperative localization of peripheral GGNs with excellent results.

Intraoperative Localization of STN During DBS Surgery Using a Data-Driven Model.

A new approach is presented for localizing the Subthalamic Nucleus (STN) during Deep Brain Stimulation (DBS) surgery based on microelectrode recordings (MERs). DBS is an accepted treatment for individuals living with Parkinson's Disease (PD). This surgery involves implantation of a permanent electrode inside the STN to deliver electrical current. Since the STN is a very small region inside the brain, accurate placement of an electrode is a challenging task for the surgical team. Prior to placement of the permanent electrode, microelectrode recordings of brain activity are used intraoperatively to localize the STN. The placement of the electrode and the success of the therapy depend on this location. In this paper, an objective approach is implemented to help the surgical team in localizing the STN. This is achieved by processing the MER signals and extracting features during the surgery to be used in a Machine Learning (ML) algorithm for defining the neurophysiological borders of the STN. For this purpose, a new classification approach is proposed with the goal of detecting both the dorsal and the ventral borders of the STN during the surgical procedure. Results collected from 100 PD patients in this study, show that by calculating and extracting wavelet transformation features from MER signals and using a data-driven computational deep neural network model, it is possible to detect the borders of the STN with an accuracy of 92%. The proposed method can be implemented in real-time during the surgery to model the neurophysiological nonlinearity along the path of the electrode trajectory during insertion.

Biplanar X-Ray Methods for Stereotactic Intraoperative Localization in Deep Brain Stimulation Surgery.

BACKGROUND: Efficacy in deep brain stimulation (DBS) is dependent on precise positioning of electrodes within the brain. Intraoperative fluoroscopy, computed tomography (CT), or magnetic resonance imaging are used for stereotactic intraoperative localization (StIL), but the utility of biplanar X-ray has not been evaluated in detail. OBJECTIVE: To determine if analysis of orthogonal biplanar X-rays using graphical analysis (GA), ray tracing (RT), and/or perspective projection (PP) can be utilized for StIL. METHODS: A review of electrode tip positions comparing postoperative CT to X-ray methods was performed for DBS operations containing orthogonal biplanar X-ray with referential spheres and pins. RESULTS: Euclidean (Re) errors for final DBS electrode position on intraoperative X-rays vs postoperative CT using GA, RT, and PP methods averaged 1.58 mm (±0.75), 0.74 mm (±0.45), and 1.07 mm (±0.64), respectively (n = 56). GA was more accurate with a ventriculogram. RT and PP predicted positions that correlated with third ventricular structures on ventriculogram cases. RT was the most stable but required knowledge of the geometric setup. PP was more flexible than RT but required well-distributed reference points. A single case using the O-arm demonstrated Re errors of 0.43 mm and 0.28 mm for RT and PP, respectively. In addition, these techniques could also be used to calculate directional electrode rotation. CONCLUSION: GA, RT, and PP can be employed for precise StIL during DBS using orthogonal biplanar X-ray. These methods may be generalized to other stereotactic procedures or instances of biplanar imaging such as angiograms, radiosurgery, or injection therapeutics.

Transfemoral Approach for Intraoperative Angiography in the Prone or Three-quarter Prone Position : A Revisited Protocol for Intracranial Arteriovenous Malformation and Fistula Surgery.

PURPOSE: Among the different arterial accesses, the femoral access is the main approach for intraoperative angiography (IOA) performed in a prone position. Without a standardized protocol, however, the application of prone IOAs in intracranial arteriovenous malformation (AVM) or arteriovenous fistula (AVF) surgery remains limited by its procedural complexity. This study describes the detailed protocol for prone IOA through a transfemoral approach and highlights several refinements in preparing this procedure. METHODS: This study retrospectively reviewed the intracranial or high cervical AVM/AVF surgical cases in which both resection and IOA were performed in the prone or three-quarter prone position. Extended femoral sheath approaches and radiolucent head clamps were used in all cases. An aneurysm clip, serving as a localization landmark in IOA, was routinely placed within the surgical field. The IOA imaging, clinical impact of IOA, and complications related to the procedure were recorded. RESULTS: A total of six AVM and three AVF cases, operated on in the prone (n = 7) or three-quarter prone (n = 2) positions, were included. Multiple vessel injections were required in 66.7% of cases, and IOA was successfully performed in every intended vessel. All IOA images were adequate for interpretation, except for two cases in which the non-radiolucent component of the head clamp obscured the region of interest in the lateral views. Incomplete occlusion was identified in two patients, and the aneurysm clip provided precise guidance in localizing the residual nidus. Final IOA confirmed complete lesion removal in all cases, and there were no IOA-related complications. CONCLUSION: Three key steps in setting-up a prone IOA procedure for intracranial AVM/AVF surgery are proposed: (1) utilize an extended femoral sheath approach, (2) establish a localization landmark with an aneurysm clip and (3) avoid possible image interference from the non-radiolucent component of the head clamp.

Near-Infrared Polymer Dots in the Portal-Hepatic Circulation Achieve Localization of Hepatic Carcinoma In Vivo.

The present study aims to use polymer dots to explore whether they can visualize tumor lesions in a diethylnitrosamine (DENA)-induced hepatocellular carcinoma (HCC) model. The HCC rat model was set up, and serum liver function indexes and AFP were tested on days 0, 30, 60, and 90 of the modeling process. After characterization of the polymer dots, they were injected into the rats and mice. The liver, spleen, and kidney of rats and the gallbladder of mice were extracted to verify the metabolic pathways of the polymer dots and their capability of fluorescent localization of HCC and gallbladder by fluorescence imaging. Strong fluorescent emission from the liver appeared immediately and 15 min after the polymer dots were injected through the main portal veins and tail veins of the model rats, respectively. A satisfactory fluorescent imaging effect lasted up to 45 min. Polymer dots circulate through the bloodstream within intrahepatic vessels rather than intracellular areas and can be clearly visualized by using both the pCLE and IVIS spectrum imaging systems. Contrast imaging of HCC lesions without fluorescent emissions was due to the lack of normal portal-hepatic veins within the tumor areas. Fluorescent imaging of the gallbladder could also be detected at 15 min after the polymer dots were injected through the tail veins of mice. The polymer dots had satisfactory fluorescent localization capability for targeted intrahepatic vessels and HCC lesions in vivo and showed potential practical value in hepato-biliary surgery.