Journal of neuroendovascular therapy最新文献

Objective: Direct carotid-cavernous fistula (CCF) is a common neurovascular complication associated with Ehlers-Danlos syndrome (EDS). Nevertheless, reports indicate a significant incidence of treatment-related complications.

Case presentation: We present a case of right CCF in a 28-year-old female with EDS. Femoral artery and vein punctures were performed under ultrasound guidance. We executed transvenous embolization (TVE) of the draining veins and the shunted fistula using a combination of coils and n-butyl-2-cyanoacrylate (NBCA), facilitated by an assisted transarterial balloon. The CCF resolved without any procedural complications.

Conclusion: Utilizing a combination of coils and NBCA in TVE is seen as a safe and efficient method for addressing CCF in patients with EDS. It enables preserving better visualization of the cavernous sinus and adjacent structures, making this approach particularly effective. By keeping a close watch, monitoring for potential high-risk complications, and strategically placing devices between the arterial and venous sides, the arterial puncture profile is reduced, enabling safer endovascular treatment.

Objective: We retrospectively examined the risk factors for early recurrence in patients with ruptured anterior communicating artery (AcomA) aneurysms who underwent coil embolization.

Methods: Forty-four patients with ruptured AcomA aneurysms who underwent coil embolization between January 2012 and June 2021 were included. Patient backgrounds, anatomical features, intraoperative anticoagulation, and radiological findings before and after treatment were reviewed retrospectively. Univariate analysis was performed separately for each item investigated in the early recurrence (ER) and non-early recurrence (NER) groups. Additionally, the relationship between changes in embolic status (Raymond-Roy classification [RRC]) from immediately after surgery to 2 weeks later and severity of disease was investigated.

Results: Re-treatment was performed in a total of 8 (18.2%) cases. Two cases were detected and treated in the chronic phase with no re-rupture. In the ER group, 6 (13.6%) cases had RRC class 3 filling without evidence of coil compaction on digital subtraction angiography performed 2 weeks after the initial embolization, and were re-treated. The mean intraoperative activated clotting time (ACT; p = 0.0226; NER median 189.5 s, ER median 149 s), contralateral A1 diameter (p = 0.0264; NER median 0.85 mm, ER median 0.26 mm), and volume embolization rate (VER; p = 0.02, NER median 35.57%, ER median 20.86%) were significantly lower in the ER group. The more severe the Hunt and Hess grade, the worse the embolic condition (RRC) tended to be after 2 weeks (p = 0.0339).

Conclusion: In this study, factors such as low intraoperative ACT, low VER, contralateral A1 hypoplasia, and condition severity may be associated with early recurrence after acute coil embolization for ruptured AcomA aneurysms.

Objective: Persistent primitive hypoglossal artery (PPHA) is a rare vascular anomaly that can complicate carotid artery stenting (CAS) due to its role in posterior circulation perfusion. Embolic protection is required for both the anterior and posterior circulations, which increases procedural complexity. We present a novel approach utilizing double distal filter protection (DDFP) with a single guiding catheter.

Case presentation: A 69-year-old man with symptomatic internal carotid artery stenosis (ICS) and coexisting PPHA underwent successful CAS using a DDFP strategy with a single guiding catheter. Two filter devices were deployed: 1 in the distal internal carotid artery and 1 in the PPHA. Stent delivery was achieved by temporarily retrieving the PPHA filter, followed by redeployment and post-dilation. No perioperative complications occurred. Imaging demonstrated adequate cerebral perfusion and high-risk plaque morphology, supporting the need for dual protection. The procedure minimized access-related risks and maintained perfusion throughout.

Conclusion: We successfully performed CAS in a patient with PPHA using a DDFP with a single guiding catheter technique. This technique may reduce procedural complexity while maintaining robust embolic protection, offering a safe alternative to traditional dual-catheter strategies.

Objective: Endovascular treatment of wide-neck cerebral aneurysms with conventional coiling alone remains challenging. Stent-assisted coiling using a vascular reconstruction device offers an alternative strategy. This study evaluated the safety and effectiveness of the Enterprise Vascular Reconstruction Device (Cerenovus, Irvine, CA, USA) in patients with wide-neck cerebral aneurysms.

Methods: Post-marketing surveillance records were collected for all Enterprise stent usage using case report forms at 30 days and at 1, 2, and 3 years post-procedure. A total of 738 cases, including 411 on-label cases, were analyzed across 83 hospitals.

Results: Stent deployment was successful in 98.8% of cases, and the overall procedure success rate was 93.9% immediately post-procedure. The aneurysm occlusion rate was 92.90%, with 73.7% classified as Raymond-Roy class I/II immediately post-procedure. Among the 411 on-label cases, 17 patients (4.1%) demonstrated worsening of the modified Rankin Scale score, but no deaths were attributable to the utilization of the Enterprise device. The postoperative ischemic stroke complication rate was low (4.5%) but increased significantly in patients with a proximal parent artery diameter <2.5 mm (18.6%) and in those aged ≥65 years (8%). Multivariable logistic regression revealed that age ≥65 years, diabetes, hypertension, and a past medical history of ischemic stroke were significant risk factors for postoperative ischemic stroke.

Conclusion: Vascular reconstruction device implantation was effective and safe for treating wide-neck cerebral aneurysms.

Objective: We report a unique case of carotid artery stenting (CAS) conducted via direct puncture of an aortic arch graft in a patient who underwent total arch replacement (TAR), complicated by carotid artery dissection.

Case presentation: A 72-year-old woman underwent TAR for an ascending aortic aneurysm. Aortic dissection extending to the right carotid artery was detected immediately after the aortic arch graft anastomosis, which resulted in severe stenosis and decreased cerebral perfusion. Therefore, urgent revascularization was deemed necessary. The aortic arch graft was directly punctured, followed by the placement of 3 stents to seal the dissection. Postoperative imaging confirmed the restoration of blood flow without ischemic complications. The patient, who recovered without neurological deficits or cardiosurgical complications, has remained event-free for 3 years after the intervention.

Conclusion: Direct puncture of the aortic arch graft provides a reliable and rapid access route for CAS in patients undergoing carotid artery dissection following TAR. This method may serve as an alternative when conventional access is difficult. Antithrombotic therapy should be strictly controlled to avoid procedure-related complications.

Objective: Nickel allergy is one of the most common forms of metal hypersensitivity, yet its relevance to neuroendovascular therapy has rarely been reported. We describe 3 cases of unruptured intracranial aneurysms in patients with confirmed nickel allergy, and review the literature to highlight safe endovascular management strategies.

Case presentation: Three female patients (2 in their 70s and 1 in her 60s) were incidentally diagnosed with unruptured intracranial aneurysms located at the internal carotid artery (n = 2) and the vertebral artery (n = 1). All patients tested positive on patch testing for nickel. To minimize allergic risk, devices with low nickel content were chosen, including bare platinum coils (i-ED coils; Kaneka Medix, Osaka, Japan) and a flow diverter (Surpass Evolve; Stryker, Kalamazoo, MI, USA). Endovascular treatment was completed without perioperative complications, and no allergic reactions were observed during a mean follow-up of 12.7 months. Corticosteroids were not administered in any of the cases.

Conclusion: Endovascular treatment of unruptured intracranial aneurysms in patients with nickel allergy can be performed safely by avoiding devices with high nickel content and by performing preoperative allergy testing. Awareness of device materials is critical for preventing adverse reactions and ensuring favorable outcomes.

Objective: Persistent left superior vena cava (PLSVC) is rare, occurring in approximately 0.3%-0.5% of the population. In endovascular treatment (EVT), the left internal jugular vein (IJV) is approached via the left innominate vein from the superior vena cava; however, the left innominate vein is occasionally absent in patients with PLSVC. Careful consideration is required when performing EVT, particularly transvenous embolization (TVE).

Case presentation: A 70-year-old female presented with a left cavernous sinus dural arteriovenous fistula. Left external carotid angiography findings showed that multiple feeders from the ascending pharyngeal artery, accessory meningeal artery, middle meningeal artery, and the artery of the foramen rotundum had formed a shunted pouch posterolateral to the left cavernous sinus. We initially planned to perform a TVE via the right femoral vein. However, PLSVC was detected on common carotid artery angiography. Consequently, a TVE via the left IJV and coil embolization were performed, resulting in the disappearance of the shunt. The patient was discharged without neurological deficits. PLSVC is a rarely observed thoracic venous malformation, with few reports concerning its management in cerebrovascular EVT. Contrast-enhanced computed tomography is useful for diagnosis; however, most patients with PLSVC are clinically asymptomatic and this abnormality is typically an incidental finding, remaining challenging to detect during a preoperative examination.

Conclusion: It is essential to consider the possibility of PLSVC and to verify the appropriate access route, including the right atrial level and the venous phase, during preoperative cerebral angiography.

Various types of embolic substances are used in endovascular therapy, and understanding their characteristics, including shape and kinetics, is essential for proper use. Cyanoacrylate is a typical liquid embolization agent that can be applied to many cerebral neurovascular lesions. It is injected as a mixture with ethiodized oil to provide radiopacity and regulate the polymerization rate. This review describes the characteristics, action mechanisms, techniques of use, and potential pitfalls of using cyanoacrylate-ethiodized oil mixtures for embolization.

Objective: The prognosis of patients with subarachnoid hemorrhage (SAH) who also develop cardiopulmonary arrest (CPA) is highly unfavorable, and hence they are often not aggressively treated. Presently, the therapeutic indications and factors that affect the prognosis of patients who experienced CPA remain unclear. Therefore, we analyzed SAH patients who experienced CPA, comparing the characteristics of the patients who survived with those who did not.

Methods: The 36 patients were divided into the survivor group (n = 4) and the dead group (n = 32). The patient's age, sex, location of the aneurysm, the presence of intracranial hematoma, duration of cardiopulmonary resuscitation (CPR), the presence/absence of bystanders, initial electrocardiogram waveform, recovery of brainstem reflexes with motor response, and administration of vasopressors were compared between the 2 groups.

Results: There were no significant differences in age, sex, location of the aneurysm, and presence of intracranial hematoma between the 2 groups. More than 90% of patients in the dead group had a non-shockable rhythm on the initial electrocardiogram waveform. The duration of CPR in the survivor group tended to be shorter than that in the dead group. Bystander CPR was performed on 14 patients, including all 4 of the survivors. All patients in the survivor group achieved recovery of brainstem reflexes with motor response. In the survivor group, all patients either did not need or only transiently needed the administration of vasopressors after the return of spontaneous circulation (ROSC).

Conclusion: Our analysis suggested the following as favorable prognostic factors in SAH patients with CPA: shockable arrhythmia on the initial electrocardiogram waveform, young age, bystander CPR, a short time from CPA to ROSC, recovery of brainstem reflexes with a motor response, and no or transient use of vasopressors. Our results indicate that aggressive treatment may be indicated in SAH patients with CPA who have stable vitals and show improvements in neurological symptoms.

Objective: Presurgical identification of the artery of Adamkiewicz (AKA) is crucial in thoracic and lumbar spinal lesions. Although CTA is widely employed to identify AKA, the detection rate varies across reports and is often difficult, especially in patients with spinal dural arteriovenous fistulas (SDAVFs). We report 2 cases where sublingual administration of nitroglycerin (NTG), a vasodilator, before CTA enabled good visualization of the AKA in patients with SDAVF.

Case presentation: (Case 1) A patient in his 60s presented with progressive gait disturbance, and an MRI revealed a spinal vascular lesion. CTA with sublingual NTG administration revealed an SDAVF supplied by the right seventh intercostal artery and an AKA branching from the left ninth intercostal artery. A chronic descending aortic dissection was identified on CTA, but spinal angiography was not performed. The patient was successfully managed with direct surgical disconnection of the SDAVF, and his symptoms improved. (Case 2) A patient in his 60s presented with progressive bilateral lower-limb numbness, and a thoracic SDAVF was diagnosed using MRI. CTA without NTG administration failed to identify the AKA, but after the administration of NTG, a clear depiction of the AKA branching from the left 10th intercostal artery was obtained. Endovascular shunt occlusion was successfully performed via the right 10th intercostal artery, resulting in significant symptom improvement.

Conclusion: Sublingual NTG administration before CTA may improve AKA expression in patients with SDAVF.