Single-position surgery with intraoperative digital subtraction angiography via a transpopliteal approach for complex...

Intraspinal vascular lesions, including dural arteriovenous fistulas (DAVFs) and arteriovenous malformations (AVMs), require accurate intraoperative localization and complete obliteration to prevent irreversible neurological deficits. Conventional transfemoral digital subtraction angiography (DSA) is often limited by patient repositioning during spinal surgery. This study describes a single-position technique integrating microsurgical resection with intraoperative DSA via a transpopliteal approach in the prone position.

Three patients (1 AVM, 2 DAVFs) underwent microsurgical treatment with intraoperative DSA through ultrasound-guided left popliteal artery access in a hybrid operating room. Angiography enabled precise localization before durotomy and confirmation of complete obliteration after lesion disconnection without repositioning. Real-time visualization of feeding arteries and draining veins facilitated accurate microsurgical intervention. Intraoperative neurophysiological signals were preserved or improved in all cases. Postoperative MRI and DSA confirmed complete lesion removal and regression of spinal cord edema. No access-related complications were observed, and all patients demonstrated favorable neurological recovery.

The single-position transpopliteal intraoperative DSA is a safe and efficient approach for complex spinal vascular lesions. Standardized positioning, risk-based access site selection, and integration of intraoperative neurophysiological monitoring enhance precision and safety. These refinements streamline workflow and support reproducible adoption in advanced spinal vascular surgery. https://thejns.org/doi/10.3171/CASE26156.