Journal of neuroendovascular therapy最新文献

Objective: The snare-assisted stabilization technique can address difficult catheter access in cases such as type III aortic arch. This technique can provide additional support to the treatment system, and it has received attention again in the current era of distal access catheter. Because there are a limited number of reports on this technique, the current study showed the details of this technique and also evaluated the usefulness and safety of the snare-assisted stabilization technique.

Case presentation: This is a retrospective observational study at a single center. The consequent cases using the snare-assisted stabilization technique from November 2016 to December 2024 were retrospectively reviewed. The main endpoints were morbidity, mortality rate at discharge, and the success ratio of treatments using this technique. This study included 20 patients. The patients' median age was 73 years, and 70% (n = 14) were men. The primary causes of difficult catheter access included torturous or narrow vertebral artery (n = 13, 65%), type III aortic arch (n = 5, 25%), and short-segment common carotid artery proximal to the lesion (n = 2, 10%). The snare-assisted stabilization technique consistently facilitated improved support, resulting in successful procedures in all cases. In 95% (n = 19) of the cases, the procedures were completed without complications.

Conclusion: The snare-assisted stabilization technique is effective and safe for improving the guiding system support and addressing catheter access challenges. This technique should come back into the spotlight in the era of distal access catheters.

Objective: 3D DSA performed under carotid artery occlusion tests (Matas and Alcock test) while the operator manually compresses the patient's carotid artery may be performed as a preoperative evaluation. However, few known studies have quantified the operator's radiation exposure dose during 3D DSA under carotid artery occlusion tests. In this study, we measured the changes in the operator's radiation exposure dose during such imaging under different protective measures and assessed alternative protective measures for hand exposure apart from protective gloves and the operator's head and neck orientation, proposing a new protection method.

Methods: We measured changes in the operator's radiation exposure dose under different protective measures. Specifically, we measured changes in lens dose on the operator's head and neck orientation and the use of protective equipment. Furthermore, we evaluated alternative protective measures for hand exposure aside from protective gloves.

Results: In all measurement points, the lower measured dose was recorded when protective measures were implemented. The measured doses to the left and right lenses varied depending on the usage of protective equipment and the orientation of the operator's head and neck. The lowest measured dose to both lenses was recorded when the protective equipment and ceiling-suspended shield were used, and the operator's head and neck were turned toward the subject. The hand dose was the lowest when protective gloves were used (316.9 μGy), representing a 72% reduction compared with unprotected conditions. When the neck guard or lead plate was inserted underneath the measurement points, the hand dose decreased by approximately 29% (884.3 μGy) and 43% (657.6 μGy), respectively, compared with unprotected conditions.

Conclusion: Our findings confirmed that operator radiation exposure dose can be reduced through protective measures. The lens exposure dose was minimized when protective equipment and the ceiling-suspended shield were used, and the operator's head and neck were turned toward the subject. While the protective effect of the lead plates was lower than that of protective gloves-which can be challenging to use during manual compression-the method of inserting a lead plate beneath the patient table and bending it along the shoulder was identified as another useful alternative.

Objective: Compared with stent-assisted coiling (SAC), the Woven EndoBridge (WEB; Terumo Neuro, Aliso Viejo, CA, USA) device has been reported to reduce procedural duration, suggesting the potential to reduce radiation exposure for both patients and operators. However, whether WEB treatment results in lower radiation exposure than SAC has not been fully investigated. This study therefore aimed to evaluate radiation exposure associated with WEB treatment versus SAC in the management of unruptured wide-neck bifurcation aneurysms (WNBAs).

Methods: We retrospectively analyzed 46 patients treated for 47 unruptured intracranial aneurysms located at the basilar artery apex, middle cerebral artery bifurcation, or anterior communicating artery at our institution between February 2023 and April 2024. Patients were categorized into 2 groups based on the treatment modality: SAC or WEB device. Radiation exposure, fluoroscopy time, procedure duration, and number of imaging procedures were compared between groups.

Results: Baseline characteristics, including age, sex, and aneurysm location, did not differ significantly between groups. However, aneurysms were significantly larger in the WEB group, with both greater median aneurysm volume (61.9 vs. 43.2 mm³, P <0.001) and maximum dome diameter (8.2 vs. 5.4 mm, P <0.001). Radiation exposure was significantly lower in the WEB group, as indicated by lower median values for both air kerma (1888 vs. 3496 mGy, P <0.001) and dose-area product (126.3 vs. 158.9 Gy·cm², P = 0.002). The WEB group also showed significantly shorter values for both fluoroscopy time (49.1 vs. 102.3 min, P = 0.003) and procedure duration (97 vs. 146 min, P = 0.01). The number of imaging procedures and contrast medium volume did not differ significantly between groups.

Conclusion: In the endovascular treatment of unruptured WNBAs, the WEB device significantly reduces radiation exposure compared with SAC, primarily by decreasing fluoroscopy time. Given this potential to minimize radiation exposure, the WEB device may be preferable when both methods are clinically viable.

Objective: In recent years, mechanical thrombectomy and aspiration catheter technology have advanced significantly, with newer aspiration catheters (ACs) featuring larger lumens and improved outcomes. However, the specific features driving these improvements remain unclear. The aim of this study was to compare treatment outcomes between the latest-generation large-bore ACs (LACs) and conventional aspiration catheters (CACs) in patients undergoing mechanical thrombectomy.

Methods: In this retrospective single-center cohort study conducted at the authors' institution, we analyzed data from patients who underwent mechanical thrombectomy using ACs for internal carotid artery (ICA) or M1 segment middle cerebral artery (M1) occlusions between November 2017 and October 2022. Cases were classified into LAC (inner diameter ≥0.0710 inches) and CAC groups. Patient demographics and procedural features were evaluated, including 1st-pass effect (FPE), catheter-to-vessel match (CVM), and clot contact rates. Group comparisons were performed using the Mann-Whitney U-test or the chi-squared test. Univariate and multivariate logistic regression analyses were conducted for M1 occlusion cases treated with LACs.

Results: The study cohort comprised 159 patients who underwent mechanical thrombectomy using ACs. The FPE success rate was significantly higher in the LAC group (52.8%) than in the CAC group (34.0%). With regard to the occlusion site, this rate was not significantly different between the LAC and CAC groups for ICA occlusions; however, for M1 occlusions, the LAC group demonstrated a significantly higher FPE rate than the CAC group (P = 0.009). CVM and clot contact rates were significantly higher in the LAC group (P = 0.001 and P ≤0.0001, respectively). In the LAC group, both CVM and clot contact were independently associated with FPE success in cases of M1 occlusion (odds ratio, 10.9; 95% confidence interval, 3.3-36.7; P <0.0001; odds ratio, 18.0; 95% confidence interval, 1.9-172.9; P = 0.013, respectively).

Conclusion: LACs yielded significantly better outcomes for M1 occlusions than CACs. The enhanced FPE rate appears attributable to 2 design advantages: increased bore size, which improves CVM, and superior trackability, which enhances clot contact. These findings suggest that, given the vessel diameter variations caused by factors beyond anatomical location, tailoring mechanical thrombectomy methods and device selection to individual vascular anatomy, rather than relying on fixed vessel-based criteria, may improve treatment outcomes.

Objective: Embolization of thrombus to a new vascular territory (ENT) is a feared and important complication of cerebral thrombectomy in acute ischemic stroke. This study explores the utilization of 2 simultaneous stent retrievers to prevent ENT, as well as its alternative setups.

Methods: An in vitro glass model with a unilateral anterior cerebral vasculature was used to recreate a challenging scenario that intrinsically facilitates ENT. Four different thrombectomy techniques were tested and compared across a total of 50 in vitro procedures: Technique [1]-single stent retriever; Techniques [2] and [3]-dual stent retrievers with asymmetric and symmetric stent retrieval, respectively; and Technique [4]-dual stent retrievers combined with distal aspiration. The success rate and time to perform the procedures were compared using the Fisher's exact test and Mann-Whitney U test, respectively.

Results: The collective performance of dual-stent techniques [2 + 3 + 4] yielded successful recanalization on 1st pass without ENT in 24/30 cases (80%), which was statistically significantly better than the 8/20 (40%) achieved with the single-stent technique [1] (p = 0.006). The dual stent retrievers combined with an aspiration catheter [4] performed best, yielding successful recanalization on 1st pass without ENT in 10/10 cases (100%), which was also statistically significantly better compared to the single-stent technique [1] (p = 0.002). All other possible comparisons across the different techniques did not yield any statistically significant differences.

Conclusion: Overall, the results suggest that applying dual stent retrievers performs better than the single-stent-retrieval technique in preventing ENT and achieving a single-pass procedure. Among all techniques, combining dual stent retrievers with aspiration through a distal catheter performed best.

Objective: Endovascular treatment of cerebrovascular diseases can be challenging in patients with difficult access routes. We describe a turn-over technique using a balloon guiding catheter (BGC) via the transfemoral approach to perform neuroendovascular treatment.

Case presentation: An 80-year-old female with a recurrent right middle cerebral artery (MCA) aneurysm after coil embolization underwent successful stent-assisted coiling via the transfemoral approach. The turn-over technique using a BGC proved effective for the difficult access route via the transfemoral approach. The guidewire and inner catheter were turned over above the aortic valve, and the BGC was advanced to the right subclavian artery. The guiding balloon was inflated, and the catheter shaft was pulled to release the loop on the aortic valve. Under roadmap guidance, the guidewire and inner catheter were advanced into the right internal carotid artery (ICA). After that, by using the balloon inflation anchoring technique, we carefully guided them to the right cervical ICA while preventing slippage.

Conclusion: The turn-over technique using a BGC via the transfemoral approach may offer a viable treatment option for patients with difficult vascular access.

Objective: Heparin-induced thrombocytopenia (HIT) is a prothrombotic, immune-mediated complication of heparin therapy. In urgent neuroendovascular procedures, alternative anticoagulation strategies are crucial for mitigating thrombotic risk. Argatroban is a potential substitute; however, its use in neurointervention remains limited. This report describes a case of successful endovascular retreatment using argatroban in a patient with active HIT and includes a literature review to clarify optimal administration protocols, dosages, and monitoring strategies.

Case presentation: A 77-year-old man with dural arteriovenous fistula (dAVF) developed HIT following initial endovascular embolization. Due to recurrent cortical venous reflux and a high risk of rebleeding, urgent retreatment was performed using argatroban. An intermittent bolus strategy was employed, with dosing adjusted every 30 minutes based on activated clotting time (ACT) to maintain ACT ≥200 seconds. Complete shunt obliteration was achieved without any ischemic or hemorrhagic complications. HIT antibodies became negative 3 months later.

Conclusion: Argatroban is a viable and safe alternative to heparin in neuroendovascular procedures for patients with HIT. Intermittent bolus administration guided by ACT offers precise, situation-specific control and may be particularly appropriate for hemorrhagic cerebrovascular conditions such as dAVFs.

Objective: The Leonis Mova (SB-Kawasumi Laboratories, Kanagawa, Japan) is a steerable microcatheter with a hand-operated dial that can be used to adjust the angle of the catheter tip. This steerable microcatheter has predominantly been used as an intermediate catheter. Herein, we report a case in which an aneurysmal subarachnoid hemorrhage was treated with coil embolization using the Leonis Mova microcatheter.

Case presentation: A 53-year-old woman was transferred to our hospital for the treatment of a sudden onset of headache and vomiting caused by a subarachnoid hemorrhage detected on CT. DSA showed a 7.5-mm left internal carotid artery-posterior communicating artery aneurysm with multiple blebs, which we treated with coil embolization under general anesthesia. After placement of a 7-Fr guiding sheath in the left internal carotid artery, we introduced the Leonis Mova Selective microcatheter and the Excelsior SL-10 microcatheter (Stryker, Kalamazoo, MI, USA) into the center of the aneurysm. We inserted 9 coils into the aneurysm via the double-catheter technique, during which we adjusted the angle of the Leonis Mova microcatheter to fill each bleb in a piecemeal fashion. Almost complete obliteration was achieved, and the patient was ambulatory and discharged after completing treatment for the vasospasm phase of a subarachnoid hemorrhage.

Conclusion: The Leonis Mova may be a useful microcatheter for coil embolization of aneurysms with multiple blebs and a tortuous parent artery.

Objective: Mechanical thrombectomy alters cerebrovascular hemodynamics in ways that remain poorly characterized. This in vitro study investigated the pressure restoration rate (PRR), a quantitative measure of how quickly pressure returns to baseline in an occluded vessel, during thrombectomy using aspiration and stent-retriever devices in different cerebrovascular anatomical configurations.

Methods: A cerebrovascular glass model with pulsatile flow was constructed to simulate good (symmetrically connected) and poor (unilateral) collateral anatomy. Pressure sensors were integrated into the system to record hemodynamic responses during thrombectomy procedures using SOFIA 5F and 6F aspiration catheters (Terumo Neuro, Aliso Viejo, CA, USA) and a Solitaire 6 × 30-mm stent retriever (Medtronic, Irvine, CA, USA). PRR was calculated in the middle cerebral artery at a 5-ms resolution and compared across devices and anatomical variants using Kruskal-Wallis tests.

Results: Aspiration thrombectomy exhibited significantly higher PRRs than the stent-retriever thrombectomy across both good and poor collateral models (p <0.05). Median PRRs were 17.9 μmmHg/5 ms (SOFIA 5F), 13.5-14.3 μmmHg/5 ms (SOFIA 6F), and 0.8-1.3 μmmHg/5 ms (stent retriever). Aspiration was associated with a rapid, near-instantaneous return to baseline pressure, whereas stent-retriever thrombectomy produced a more gradual restoration with a plateau phase followed by a lower magnitude instantaneous return. Momentary reciprocal pressure fluctuations were also observed in neighboring vessels during clot removal.

Conclusion: This study demonstrates that thrombectomy induces different hemodynamic flow return patterns in the targeted vessel, with technique-specific PRR values. High PRRs, particularly with aspiration, may subject compromised cerebral vessels to potentially injurious pressure surges during reperfusion. These findings suggest a possible mechanistic link between device-technique modality and complications such as hemorrhagic transformation, warranting further investigation in clinical settings.

Objective: Symptomatic vasospasm (SVS) affects the outcomes of patients with subarachnoid hemorrhage (SAH) and often requires endovascular treatment. Hyponatremia is a predictor of SVS; however, no guidelines have recommended an absolute serum sodium value for SVS prevention. This study aimed to identify factors that influence SVS in patients with low-grade SAH and determine a specific threshold of serum sodium level that predicts SVS.

Methods: We conducted a multicenter, retrospective study of 216 patients with aneurysmal SAH grades I-III (World Federation of Neurological Societies scale). Patients were divided into the endovascular treatment-needed vasospasm (etVS) group (n = 29) and non-etVS group (n = 187). The minimum serum sodium level (minNa) was determined in the initial 2 weeks after SAH onset.

Results: The minNa of the etVS group (median 132 mmol/L) was significantly lower compared to that of the non-etVS group (median 136 mmol/L) (p <0.001). The receiver operating characteristic curve revealed that a threshold minNa of 133 mmol/L predicted the development of etVS (sensitivity 0.797 and specificity 0.552), and the area under the curve was 0.703 (95% confidence interval [CI]: 0.591-0.815). The odds ratios for etVS in patients with a minNa ≤128 mmol/L and 129-132 mmol/L were 6.79 (95% CI: 2.24-20.51) and 2.96 (95% CI: 0.90-9.73), respectively, when compared to those with a minNa 133-136 mmol/L.

Conclusion: Serum sodium levels were a predictor of etVS in patients with low-grade SAH. This is the first study to identify a threshold of serum sodium level for predicting etVS, aiding clinicians in setting a management goal for SVS prevention.