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• Correspondence on "Intraoperative angiography in neurosurgery: temporal trend, access site, and operative indication considerations from a 6-year institutional experience" by Tudor et al.
  Liangjing Xia, Hao Chi, Yuquan Chen and Qiang Cao
  Published on: 11 November 2024

• Published on: 11 November 2024

  Correspondence on "Intraoperative angiography in neurosurgery: temporal trend, access site, and operative indication considerations from a 6-year institutional experience" by Tudor et al.

  • Liangjing Xia, Professor, Hong Kong Baptist University Hong Kong Baptist University
  • Other Contributors:
    • Hao Chi, Professor, Southwest Medical University
    • Yuquan Chen, Monash University, PhD candidate
    • Qiang Cao, Kunming University of Science and Technology, Professor

  We read with great interest the recent article by Tudor et al.[1] on intraoperative angiography (IOA) trends and access site considerations in neurosurgery. The study provides valuable insights into the temporal evolution of vascular access strategies and the operational dynamics surrounding transfemoral and wrist access approaches. However, we wish to raise some concerns and propose recommendations for the refinement of future analyses in this domain.

  Firstly, the authors concluded that the transradial approach (TRA) and transulnar approach (TUA) are equally safe and effective as the transfemoral approach (TFA) for IOA, based on the lack of significant differences in radiation exposure and contrast dose when controlling for several confounders. However, the multivariate regression model fails to adequately account for potential learning curve effects that may differentially influence metrics such as fluoroscopy time and contrast dose across access sites. This limitation is particularly critical as it overlooks operator-dependent variability, which is an important determinant of access site-related outcomes. Incorporating institutional-level stratified analysis by trainee involvement and operator experience would have added depth to the study.

  Secondly, the analysis aggregated TRA and TUA cases into a composite wrist access group for statistical comparisons. While this approach increases the sample size, it risks masking distinct differences betwe...

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  We read with great interest the recent article by Tudor et al.[1] on intraoperative angiography (IOA) trends and access site considerations in neurosurgery. The study provides valuable insights into the temporal evolution of vascular access strategies and the operational dynamics surrounding transfemoral and wrist access approaches. However, we wish to raise some concerns and propose recommendations for the refinement of future analyses in this domain.

  Firstly, the authors concluded that the transradial approach (TRA) and transulnar approach (TUA) are equally safe and effective as the transfemoral approach (TFA) for IOA, based on the lack of significant differences in radiation exposure and contrast dose when controlling for several confounders. However, the multivariate regression model fails to adequately account for potential learning curve effects that may differentially influence metrics such as fluoroscopy time and contrast dose across access sites. This limitation is particularly critical as it overlooks operator-dependent variability, which is an important determinant of access site-related outcomes. Incorporating institutional-level stratified analysis by trainee involvement and operator experience would have added depth to the study.

  Secondly, the analysis aggregated TRA and TUA cases into a composite wrist access group for statistical comparisons. While this approach increases the sample size, it risks masking distinct differences between these access techniques, particularly given the anatomical and procedural nuances associated with the radial and ulnar arteries. A separate analysis of TRA and TUA metrics might elucidate unique strengths and limitations of each approach and yield a more granular understanding of their clinical applicability.

  Thirdly, while the study examines radiation exposure and contrast dose metrics, it does not provide a detailed risk assessment of angiography-related complications beyond access site hematomas. For instance, minor neurological symptoms or subclinical embolic events, which might be underreported without systematic follow-up imaging, warrant further investigation. Future studies should consider adopting a standardized postoperative monitoring protocol to ensure comprehensive safety evaluations.

  Lastly, while the temporal trend analysis highlights an increasing adoption of wrist access techniques, the introduction of a hybrid operating room setup during the study period represents a confounding variable that is insufficiently explored. The hybrid environment may independently reduce radiation exposure and improve operative efficiency, regardless of the access site employed. A subgroup analysis pre- and post-hybrid room implementation could help disentangle the relative contributions of access site changes versus technological advancements to the observed outcomes.

  We commend the authors for their thorough exploration of intraoperative angiography access trends and outcomes. Addressing the outlined methodological and analytical limitations would enhance the robustness and generalizability of the findings, providing even greater value to the neurointerventional community.

  References
  [1]Tudor T, Sussman J, Sioutas G S, et al. Intraoperative angiography in neurosurgery: temporal trend, access site, and operative indication considerations from a 6-year institutional experience[J]. Journal of NeuroInterventional Surgery, 2024, 16(11): 1187-1193. doi: 10.1136/jnis-2023-020709

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  Conflict of Interest:
  None declared.

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