Purpose: Anatomical factors involved in the difficulty of inserting a guiding catheter (GC) into the aortic arch include marked arteriosclerosis with severe vessel tortuosity and type-3/bovine aortic arches. For patients with such factors, we have inserted a balloon guiding catheter (BGC) using the balloon-inflation anchoring technique (BIAT). In this study, we introduce the BIAT, and examine its usefulness.

Subjects and Methods: The subjects were 44 patients who underwent acute mechanical thrombectomy for occlusion of the major cerebral artery in anterior circulation between January 2014 and February 2016. Of these, the BIAT was used for BGC insertion in patients, with the above anatomical factors, in whom it was difficult to insert a BGC using the standard method. The BIAT is a technique with a BGC in which an inner catheter is guided to the peripheral side by dilating/anchoring a balloon at maximum at the origin of the brachiocephalic trunk or left common carotid artery, and, subsequently, a BGC is guided to the target blood vessel by slightly deflating the balloon as a flow-guide.

Results: Of the 44 patients, BGC insertion was difficult in eight patients (18%). The mean age of the other patients (control group) was 68.9 years, whereas that of the eight patients was 79.7 years, being significantly more advanced (p = 0.025). The BIAT facilitated BGC insertion in all patients, and the technical success rate was 100%. There were no procedure-related complications. The mean interval from the start of femoral artery puncture until BGC insertion was 15.7 and 20.3 minutes, respectively, in the control and BIAT groups. There was no significant difference between the two groups (p = 0.35).

Conclusion: In 18% of patients who underwent acute mechanical thrombectomy, BGC insertion was difficult. In this group, the proportion of elderly patients was significantly higher. The BIAT facilitated BGC insertion in all patients. The mean interval from the start of puncture until BGC insertion was 20 minutes; a BGC could be guided in a relatively short period. This procedure may be particularly useful for acute mechanical thrombectomy, of which the duration directly contributes to the outcome.

Objective: Since stenting for assisting cerebral aneurysm embolization was approved, the therapeutic results of coil embolization for cerebral aneurysm have improved. However, various complications due to stent placement, including thromboembolism, have also been reported.

Materials and Methods: In 32 patients who could be followed up after stent-assisted coil embolization of cerebral aneurysms, chronological changes in the aneurysmal occlusion and characteristic complications were evaluated.

Results: The aneurysmal occlusion immediately after the treatment was complete occlusion (CO) in 6 patients (18.8%), neck remnant (NR) in 10 patients (31.1%), and body filling (BF) in 16 patients (50.0%). The aneurysmal occlusion at the follow-up was CO in 17 patients (53.1%), and aneurysmal obliteration was advanced in 14 patients (43.8%) during the follow-up period. As there are complications due to stent placement, occlusion of the parent vessel was noted during the treatment in one patient, and stenosis or kinking of the parent vessel or branches was observed during the follow-up in four patients. Of these four patients, two patients showed in-stent stenosis, one patient showed kinking of the parent vessel associated with linearization of the vessel by stenting, and one patient showed stenosis of a vessel branching from the site of stenting. All were asymptomatic.

Conclusion: Serial improvements in the aneurysmal occlusion were observed after stent-assisted coil embolization. Stenosis due to stretching of the parent vessel as well as in-stent embolization or stenosis may occur as characteristic complications of stenting, and long-term follow-up is necessary.

Purpose: We examined postoperative stent and lumen expansions after carotid artery stenting (CAS) in patients with carotid artery stenosis. Furthermore, we investigated factors influencing the stent and lumen expansions in a follow-up period.

Subjects: 134 cases (128 patients) who underwent CAS and performed follow-up cerebral angiography 12 months after CAS were enrolled into this study. The stenosis rate based on the stent and lumen diameters on follow-up angiography as a percentage of that immediately after CAS was evaluated.

Results: Both the stent and lumen diameters were significantly dilated 12 months after CAS (p <0.001). There were no significant stent-type-related differences in the stent expansion rate. In the symptomatic stenosis group, this expansion rate was significantly higher than in the asymptomatic stenosis group (p = 0.02). With respect to the presence or absence of a high signal intensity on time of flight (TOF) magnetic resonance (MR) images, the stent expansion rate was significantly higher in the high signal intensity group (p = 0.006). In patients with a plaque/sternocleidomastoid muscle signal intensity ratio of ≥1.50 on plaque images, it was significantly higher than in those with a value of <1.50 (p = 0.006). However, there were no significant differences in the lumen expansion rate among the groups.

Conclusion: Both the stent and vascular lumen were dilated 12 months after CAS. Plaque fragility influenced the stent expansion rate; however, there were no significant factor-related differences in the vascular lumen expansion rate.

Objective: Craniofacial injury with fracture may lead to pseudoaneurysm formation in the external carotid artery system, causing massive epistaxis. In this study, we report a patient with intermittent epistaxis related to a traumatic aneurysm following right blow-out fracture, and review the literature with respect to the pathogenesis and treatment of traumatic aneurysms.

Case Presentation: The patient is a 91-year-old male. He had undergone conservative treatment for right blow-out fracture because he fell down while walking. Subsequently, he had received medication with an iron preparation to control intermittent massive epistaxis. Six months after the head injury, he consulted the Department of Otorhinolaryngology with persistent epistaxis. In the right nasal cavity, a pulsatile mass was detected, suggesting a vascular lesion. He was referred to our department. Neurologically, there were no abnormalities, but marked anemia was noted, and blood transfusion was performed. Head CT revealed a mass occupying the right maxillary sinus. The mass was partially enhanced on contrast-enhanced CT. Angiography showed a pseudoaneurysm, measuring 8 × 10 × 15 mm, originating from a branch of the right internal maxillary artery. Subsequently, transarterial embolization was performed. A microcatheter was inserted to reach the aneurysm, and it was embolized using a liquid embolic material. After surgery, there was no epistaxis, and an improvement of anemia was achieved.

Conclusion: In epistaxis patients with a history of craniofacial injury, it is necessary to differentiate traumatic aneurysms. Endovascular treatment is effective for traumatic aneurysms, and should be selected as a first-choice treatment.

Objective: Vertebral arteriovenous fistula is a rare entity caused primarily by trauma and is known to occur iatrogenically after penetrating trauma of the neck and surgery of the cervical spine. We present a case of iatrogenic vertebral arteriovenous fistula that was caused by erroneous jugular vein puncture and could be radically treated by target embolization after localizing the shunt points using high-resolution cone-beam computed tomography (HR-CBCT) with a review of the literature.

Case Presentation: A 76-year-old woman with a history of coronary artery disease treated with percutaneous intervention underwent scheduled cardiac catheterization by the right radial artery and right internal jugular vein approaches. Following several test punctures of the right cervical region, a 6 Fr sheath was placed in the right jugular vein, but she began to note tinnitus around this time. As vascular bruit was heard in the neck, the patient was referred to our hospital. By MRI and angiography, left vertebral arteriovenous fistula was diagnosed. Two shunt points could be identified by preoperative HR-CBCT. Trans-arterial target embolization was performed on the vein side across the shunt points, resulting in the disappearance of the shunt flow with tinnitus and vascular bruit.

Conclusion: A case of iatrogenic vertebral arteriovenous fistula that could be radically treated by trans-arterial target embolization was reported. HR-CBCT was useful for the localization of the shunt points.

Objective: Arteriovenous fistula (AVF) at the craniocervical junction (CCJ) is a rare intracranial vascular disorder that is one cause of subarachnoid hemorrhage (SAH). We report on a rare case of AVF at the CCJ, which was mainly supplied by a branch of the posterior inferior cerebellar artery (PICA).

Case Presentations: A man in his seventies presented with severe SAH. Angiography revealed that the shunt point was placed in the vicinity of the intradural radicular vein of the right C1 nerve root, and that the C1 radicular artery (C1 RA) was also feeding the AVF. An aneurysm on the PICA branch feeding the shunt was considered a bleeding point. Taking the radiological findings into account, we made the diagnosis of radicular AVF at the CCJ. Transarterial glue embolization obliterated the aneurysm. Brain magnetic resonance (MR) imaging, however, demonstrated infarcts localized in the posterior part of the upper cervical cord and the cerebellum.

Conclusion: Arterial anastomotic channels around the CCJ can be the source of ischemic events after glue embolization.

Objective: A method for retrieving hard thrombi that prevent sufficient expansion of stent thrombus retrievers was evaluated in vitro and in vivo.

Case Presentation: Using a silicone vascular model, a method effective for retrieving hard thrombi that prevent sufficient expansion of stent thrombus retrievers was evaluated. The tip of the guidewire was shaped into a J-shape, and the stent was deployed by guiding the microcatheter to spirally penetrate the space between the thrombus and the vascular wall. The safety and reproducibility of this technique (corkscrew penetrating method) was examined. A 77-year-old woman was found lying in a street and ambulanced to our hospital. Right complete hemiplegia and aphasia were noted. A diagnosis of occlusion of the proximal left middle cerebral artery was made, and endovascular mechanical thrombectomy was carried out. Although clot retrieval was attempted using a stent retriever, the thrombus was considered hard and recanalization could not be achieved by the first pass. Therefore, the second pass was performed by the corkscrew penetrating method. When the stent was recovered, a hard and long thrombus was caught winding around the stent. Complete recanalization was achieved, and right hemiplegia was radically mitigated.

Conclusion: This method was suggested to be effective for the retrieval of hard thrombi that would prevent the expansion of the stent clot retriever and resist capture.

Objective: A compliant balloon microcatheter has been used conventionally to perform remodeling in the treatment of broad-neck intracranial aneurysms. We describe a balloon-assisted microcatheterization technique using a compliant balloon microcatheter under proximal flow control of a balloon guiding catheter for the purpose of microcatheter navigation into aneurysms with anatomical difficulty.

Case Presentations: We used this technique successfully in six patients who had non-ruptured paraclinoid aneurysms. A balloon guiding catheter is placed in the parent artery. A compliant balloon catheter is navigated to distal to the aneurysmal neck for occlusion of the distal route. After inflating the balloon of the guiding catheter, the compliant balloon is inflated. The distal balloon creates a barrier, and only the path to the aneurysm remains. Balloon inflation of the guiding catheter is helpful to stabilize a distal compliant balloon so that the balloon does not float. In addition, proximal flow control of the parent artery may prevent blood pressure from increasing inside the aneurysm and leading to aneurysm rupture when a compliant balloon is inflated distal to the aneurysmal neck.

Conclusion: If catheter detention to an aneurysm in coil embolization is anatomically hazardous, this method is easy, safe, and very useful, and an important option.