Document resource
Background Catheter angiography performed during pediatric AVM surgery offers the opportunity to identify residual nidus, but its risk-benefit profile in the modern era is not well defined. We reviewed our experience to characterize how often intraoperative angiography changes management, quantify procedure-related burden, and identify features associated with residual disease after resection.Methods We performed a retrospective multi-institutional cohort study of children who underwent microsurgical treatment of intracranial AVMs followed by intraoperative cerebral angiography at two pediatric referral centers from 1997 through 2025. Study endpoints included presence of residual disease, delayed recurrence, fluoroscopy time, radiation dose, angiography-related adverse events, and postoperative clinical outcomes. The association between residual AVM and lesion characteristics was evaluated using Firth-penalized logistic regression.Results 42 pediatric patients met study criteria and were included in this analysis. Intraoperative angiography identified persistent AVMs after the index surgery in 3 cases. One false-negative intraoperative angiogram was identified. One patient developed angiographic recurrence 75 months after surgery, even after two prior vascular studies had shown no residual disease. Intraoperative angiography demonstrated a generally favorable safety profile, with no angiography-attributable complications, a median fluoroscopy time of 2.8 minutes (IQR 3.7), and a median cumulative radiation exposure of 88.2 mGy (IQR 173.2). Of note, all residual lesions occurred in anatomically complex AVMs, defined as those with a maximum nidus diameter ≥3 cm, eloquent location, deep venous drainage, or infratentorial/posterior fossa location. Complex anatomy was associated with higher odds of residual AVM (OR 2.18), but the estimate was imprecise (95% CI 0.19-303.23) and not statistically significant (p=0.57).Conclusions Intraoperative cerebral angiography altered management in a small subset of pediatric AVM resections and was not associated with procedure-related complications in this cohort. The utility of intraoperative angiography was also greatest for lesions with challenging anatomy. These findings support a selective approach to intraoperative angiography, prioritizing it for cases where visual inspection alone may be unreliable to confirm cure. Future studies with larger samples remain needed to further inform risk-based frameworks on the use of intraoperative angiography.Disclosures S. Salas-Vega: None. S. Teti: None. S. Robles: None. T. Singer: None. B. O’Neill: None. N. Vyas: None. L. Moores: None. J. Myseros: None. C. Oluigbo: None. D. Donoho: None. H. Syed: None. R. Keating: None. M. Pearl: None. A. Feroze: None.