Managing orbital venous malformations with a hybrid procedure

Take-Home

The management of orbital vascular lesions in the endovascular operating room appears to be safe and well controlled with real-time surveillance to facilitate the surgical resection.

Managing orbital venous malformations with a hybrid procedure

How endovascular operating room serves as unique setting for novel application in ophthalmology

By Lynda Charters; Reviewed by Emmy Yuen-Mei Li, FRCS, and Hunter Kowk-lai Yuen, FCOphthHK

Hong Kong-A novel hybrid procedure for treating orbital venous malformations in the endovascular operating room-requiring collaboration among a radiologist, surgeon, and ophthalmologist-seems to be safe and well controlled with real-time, high-quality surveillance to facilitate the surgical resection.

Emmy Yuen-Mei Li, MD-in describing the features in an operating theater and an endovascular operating room-noted that the Queen Elizabeth Hospital in Hong Kong was established in 2011. The primary procedures performed there include diagnostic and therapeutic percutaneous vascular procedures, combined open and endovascular procedures, and abdominal aneurysmal stent grafts.

“An operating room is specifically designed and equipped with instruments for open surgery,” said Dr. Li, associate consultant, Hong Kong Eye Hospital, and honorary assistant clinical professor, Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong.

“Usually the operating room is equipped only with basic radiologic equipment, for example, a C-arm. An intervention radiology suite is specifically design for interventional radiology procedures; it may not contain instruments for open surgery and the infection control standards are not equal to those of an operating room,” Dr. Li said. “However, the endovascular operating room combines the benefit of both for treating vascular lesions.”

Endovascular operating room benefits

The endovascular operating room is a positive-pressure room in which standard sterilization procedures are followed. Available equipment includes appropriate digital subtraction fluoroscopic imaging equipment (digital subtraction angiographic system) and ultrasonography; surgical glue, guide wires, and catheters; and a full range of surgical instruments. Personnel include trained interventional radiologists, surgeons, nurses, and radiology technicians.

Using an endovascular operating room facilitates one-stop provision of diagnosis and treatment of vascular lesion, e.g., identification of outflow draining vessels; real-time controlled injection of glue or a sclerosant; subsequent immediate open surgical lesion removal if necessary with no patient transfers needed; open exposure of lesions for direct puncture; and complications of the endovascular procedure (residual stenosis, occlusion, bleeding) can be treated with immediate surgery, according to Dr. Li.

Digital subtraction angiography allows simultaneous biplane imaging with better three-dimensional visualization. Digital subtraction images are possible; a lower radiation dose can be used and there is less interference from bone shadows. Roadmapping allows safer canalization of the vascular lesions.

Managing orbital vascular lesions

Dr. Li recounted the experience at her institution in managing orbital vascular lesions. All patients underwent digital subtraction fluoroscopic venography to confirm the extent of the lesion and the draining pattern of the vascular lesions, especially that of any intracranial communication, she said.

For small lesions for which surgical excision was unnecessary, fluoroscopic-guided sclerotherapy with 5% ethanolamine was performed. For larger lesions, a histoacryl glue/lipiodol mixture was injected to solidify the lesion, followed by surgical resection (transconjunctival or transcutaneous) performed by oculoplastic surgeons.

In six patients (4 women, 2 men; mean age, 32 years) with a venous malformation in the periocular and orbital regions, the mean follow-up was 19.5 months (range, 14 to 24 months). Four lesions were in the left upper lid, one in the left lower lid, and one in the right upper lid.

The mean surgical time was 186 minutes (range, 91 to 324 minutes). In four of the six patients, the surgery achieved complete lesion removal clinically and radiologically. The disfigurement was corrected in all patients, and there were no lesion recurrences.

No intraoperative complications-such as intracranial spilling of sclerosant/tissue glue, cerebrovascular event, or excessive bleeding-were observed.

Postoperatively, none suffered from visual loss from the surgery.  One patient with a massive lesion had mild limitation in extraocular movement after surgery. No other adverse events-such as wound infection, secondary hemorrhage, tissue necrosis, and unsightly scar-were noted.

Novel application

Based on their experience, the investigators cited the advantages of performing the hybrid procedure in an endovascular operating room. The surgery affords more controlled hemostasis, easier removal of solidified lesion, better assessment of draining vessels, is more likely to achieve complete resection of multiloculated lesions, and decreased risk of spillage of sclerosant/glue-thus, a overall higher degree of safety, better outcome, and fewer hospital admissions with shorter hospital stays, they noted.

“The hybrid procedure for treating orbital venous malformation in the endovascular operating room is a novel application in ophthalmology,” Dr. Li said.

“It facilitates a safer, well-controlled orbital venous malformations resection with real-time, high-quality biplane digital subtraction angiography system surveillance,” she concluded. “Its success requires collaboration among interventional radiologist, surgeon, and ophthalmologist.”

Emmy Yuen-Mei Li, FRCS

E: dr.emmyli@gmail.com

This article was adapted from Dr. Li’s presentation at the 2013 meeting of the American Academy of Ophthalmology. Dr. Li has no financial interest in the subject matter.