Objective: Ventricular assist devices (VAD) are used as a bridge to heart transplantation. Cerebral embolism can develop in patients with VADs despite a strict anticoagulation therapy. We report two cases of successful acute endovascular therapy with Penumbra system for cerebral embolism.Case Presentations: Case 1: A 20-year-old woman with a VAD presented with right facial palsy and right monoparesis. 3D-computed tomography angiography (3D-CTA) demonstrated left middle cerebral artery (MCA) occlusion. We successfully performed endovascular recanalization of the left MCA with Thrombolysis in Cerebral Infarction (TICI) Grade3 perfusion, and the patient’s symptoms significantly improved. The patient’s condition improved to nearly the pre-treatment state. However, due to repeated strokes, the patient developed disturbances of consciousness, aphasia, and complete paralysis of the left lower limb. Furthermore, the infection worsened, and the patient eventually developed a circulatory disorder of the VAD and died. Case 2: A 34-year-old man with VAD presented with sudden disturbances of consciousness and right hemiparesis. Computed tomography (CT) scan revealed no early abnormalities. We performed endovascular recanalization of the left internal carotid artery (IC) top with TICI 3 perfusion. After endovascular treatment, CT scan did not reveal a cerebral infarction. The patient eventually achieved an National Institutes of Health Stroke Scale (NIHSS) score of 0 point and received a heart transplant. In case 2, we pathologically analyzed the retrieved thrombus and confirmed the thrombus to be mainly composed of fibrin. There were no complications of hemorrhage in either case.Conclusion: A suction-type thrombectomy device is believed to be the first choice for patients with VAD.

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Objective: We report a rare case of cervical internal carotid artery aneurysm associated with Marfan syndrome and the technical details of endovascular trapping.Case Presentations: A 23-year-old male who had been diagnosed with Marfan syndrome presented with dysphagia due to an enlarged left cervical pulsating mass. Imaging studies revealed a non-thrombosed, giant cervical internal carotid fusiform aneurysm measuring approximately 3–4 cm extending to the skull base. After bypass surgery between the superficial temporal artery and the middle cerebral artery, endovascular trapping of the cervical internal carotid artery at both sides of the aneurysm was performed under flow control without positioning any coils inside the aneurysm itself. A 6F distal access catheter technique through the aneurysm and double or triple microcatheter technique were useful for tight and short-length occlusion of the artery combined with a proximal balloon guiding catheter. Dysphagia resolved after treatment due to alleviation of the compression on the recurrent nerve and disappeared completely within 3 weeks.Conclusion: Distal access catheter and multiple microcatheters under proximal flow control can be useful for endovascular trapping of both sides of a cervical fusiform aneurysm.

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Objective: Treatment for ruptured dissecting aneurysms of the vertebral artery (VA) varies according to the origin of the posterior inferior cerebellar artery (PICA). However, a PICA originating from the V3 segment has not been reported.Case Presentations: A 49-year-old man with a World Federation of Neurosurgical Societies (WFNS) grade III subarachnoid hemorrhage developed headache and bilateral lower limb weakness. Computed tomographic angiography revealed a right hemorrhagic dissecting aneurysm of the VA at the V4 segment, with a PICA originating from the V3 segment. On the day after endovascular coil embolization of the parent artery, magnetic resonance imaging (MRI) identified ischemic complications of the lateral medullary, ipsilateral cerebellar hemisphere. He had no other complications and was transferred to a rehabilitation hospital with modified Rankin scale (mRS)4.Conclusion: Considering the origins of the PICA and anterior spinal artery (ASA) is important when selecting treatment for hemorrhagic vertebral artery dissecting aneurysm. The morphological features of aneurysms, such as that described herein, are challenging, and perforated vessels might become occluded and initiate ischemic complications.

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Objective: We describe a rare case of traumatic ophthalmic artery and basilar artery aneurysms treated by pure intra-aneurysmal coil embolization without any complication, although aneurysmal recanalization occurred and also re-embolization was necessary. Traumatic basilar artery aneurysm is quite rare.Case Presentations: In this case, parent arteries of above aneurysms had no tolerance for cerebral blood flow in occlusion state, as shown by balloon occlusion tests. Additionally, these parent arteries had a high degree of operative difficulty with artery bypass, because of their anatomical locations. Thus, we decided to perform purely intra-aneurysmal coil embolizations. Careful procedures were required to prevent intra-procedural aneurysm rupture and recanalization, because the wall of the traumatic aneurysm is very fragile, similar to a pseudo-aneurysm. To prevent intra-procedural aneurysm rupture, a soft coil with variable diameter loops was choiced as the framing coil. Close follow-up by angiography at 1-to 3-week intervals was performed for earlier recognition of recanalization. Respectively, these aneurysms required only one additional coil embolization for recanalization caused by coil compaction. In sub-acute phase, maturation of the surrounding fibrous aneurysm wall might occur, and it reduced the potential for recanalization.Conclusion: If problems of intra-procedural aneurysm rupture and recanalization can be avoided, pure intra-aneurysmal coil embolization will be a suitable treatment for traumatic intracranial aneurysm. We recommend use of a soft coil as the framing coil and close follow-up with angiography until the subacute phase is reached.

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Objective: To improve the safety of carotid artery stenting (CAS), reducing the risk of perioperative ischemic complications is mandatory. To achieve this, embolic protection devices (EPD) are being used in the majority of the procedure. With the GuardWire Temporary Occlusion and Aspiration System EPD, complete evacuation of the plaque debris before deflating the occlusion balloon is important to avoid cerebral thromboembolism. We report a novel method to stain the debris on the filter device to enhance the visualization of the retrieved debris so as to facilitate complete removal of the thromboembolic source.Case Presentations: The filter devices were immersed with 0.5 ml of 1% pyoktanin solution for 5 s and irrigated with saline during the CAS procedure. The pre-stained and stained filters were compared for the visibility of the debris. The pyoktanin staining enhanced the visualization of minute debris captured on the filter that was not well recognized before the staining.Conclusion: This simple technique was effective in improving the visualization of the evacuated plaque debris and may decrease distal embolism caused by previously unrecognized debris.

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Objective: In the final stage of coil embolization, microcatheter kickback often occurs and it may be difficult to fill the remaining space with a coil. To avoid microcatheter kickback and achieve successful embolization, soft type coils such as ED coil-10 Extra Soft type R (EDC-10ES) are frequently used as a finishing coil. We compared six different brands of finishing coils to evaluate the efficacy of EDC-10ES.Case Presentations: This paper presents a representative case of small cerebral aneurysm treated with only EDC-10 ES coils were presented. Furthermore, to compare the degree of coil softness and microcatheter kickback, we verified the in vitro coil performance of six different brands of finishing coils. The first experiment compared the degree of microcatheter kickback in the final stage of coil embolization and the second experiment tested the softness of the delivery wire.Conclusion: The results verified that EDC-10 ES has less microcatheter kickback in relation to both the coil and delivery wire, compared to the other finishing coils. Consequently, EDC-10 ES was evaluated as a coil with extremely high softness, allowing stable coil placement in the final stage of embolization.

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Objective: Cerebral diagnostic angiography and endovascular surgery are commonly performed via the femoral artery, which is prone to complications. The objective of this study is to describe our approach to achieve femoral access safely.Case Presentations: Between April 2014 and March 2015, we performed femoral angiography from the outer sheath of the intra-arterial cannula prior to the insertion of the sheath. Using those images, we retrospectively divided the puncture status of each patient into four categories: optimal, high-position, low-position, and post-bifurcation punctures.Of the 190 femoral punctures performed during the study period, femoral arteriograms were confirmed in 155 (81.6%) cases. In those cases, optimal, high-position, low-position, and post-bifurcation punctures accounted for 125 (80.6%), 1, 0, and 29 cases, respectively. In other words, post-bifurcation puncture could be overlooked in as many as 29/154 (18.8%) cases without femoral angiography. In the cases of post-bifurcation punctures, large sheath insertion was avoided. Overall, there were no cases of morbidity or mortality related to the puncture.Conclusion: Femoral artery angiography can visualize post-bifurcation punctures, which are not evident upon the usual fluoroscopy-guided femoral punctures. This method represents a safe and effective way to reduce the risk of complications associated with femoral artery punctures in cerebrovascular catheter angiography and neuroendovascular treatments.

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