Objective: We formulated a simulator system for catheter intervention training by developing a sliding table and an electrically controlled camera-holding C-arm and combining them with the silicone vessel model EndoVascular Evaluator (EVE). We performed simulation of mechanical thrombectomy using this system and evaluated its usability for simulation training.

Methods: After three experts in neuroendovascular treatment were given instructions for the use of this system, they performed mechanical thrombectomy by a procedure as close as possible to that in clinical situations using an artificial thrombus model simulating left middle cerebral artery occlusion, and the procedural times and maneuvers were studied. The time required for guiding catheter placement in the cervical internal carotid artery (guiding time), time required for stent placement (stent placement time), and time required for retrieval of thrombus together with the stent (stent retrieval time) were measured, and the number of movements of the sliding table and C-arm during the procedure were counted.

Results: The intended procedure could be executed faithfully by all physicians. The mean guiding, stent placement, and stent retrieval times were 185 ± 18, 387 ± 33, and 616 ± 27 seconds, respectively. The mean numbers of table and C-arm movements during the procedure were 14 ± 1.7 and 8.3 ± 0.5, respectively.

Conclusion: This system allows operators to faithfully reproduce the mechanical thrombectomy procedure and is considered to have functions necessary for simulation training of catheter intervention and performance assessment.

Purpose: Kissing aneurysms (KAs) are caused by the rare incidence of two aneurysms with different cervixes mutually contacting each other, with craniotomy surgical clipping having been reported as difficult. The objective was to investigate the treatment outcome of single-stage coil embolization using an Enterprise stent for internal carotid artery KA.

Materials and Methods: The subjects consisted of three cases and six aneurysms (women: two cases, age: 42–70 years old, average: 55.7 years old) that underwent single-stage coil embolization using an Enterprise stent. Localization of the aneurysms was as follows: internal carotid artery-ophthalmic arterial bifurcation and internal carotid artery (C3): one case; internal carotid artery-posterior communicating arterial bifurcation and anterior choroidal arterial bifurcation: two cases; wherein, the maximum aneurysm diameter was 2.8–7.6 mm (average: 5.1 mm). The technical success rate, the presence of perioperative complications, the degree of embolus follow-up cerebral angiography after treatment (4–6 months, average: after 4.7 months), and more than 3 years follow-up contrast-enhanced magnetic resonance angiography (after 3.4–4.1 years, average: after 3.7 years) were assessed.

Results: Coil embolization was successful in all cases, with no observation of perioperative complications. Upon follow-up angiography, complete occlusion (CO) was observed in all three cases and six aneurysms.

Conclusion: The initial treatment outcome of single-stage coil embolization for carotid KA using an Enterprise stent was good.

Objective: Contrast-enhanced carotid ultrasonography (CEUS) is a new technique for assessing carotid artery plaques. The present study attempted to demonstrate the association between the findings of CEUS performed prior to carotid artery stenting (CAS) and plaque debris caught during CAS.

Methods: This study was conducted with 16 patients (15 men, 1 woman; mean age: 74.8 years) who had undergone evaluation of carotid plaque vulnerability followed by CAS. The carotid plaque evaluation consisted of CEUS and MRI. The amount of debris retrieved during CAS was semi-quantitatively classified into three grades (large, moderate, and small) by three independent physicians based on inspection of photographs of retrieved debris. The existence of a correlation between CEUS findings and the amount of debris was examined.

Results: Enhanced plaque on CEUS was observed in 7 of 16 patients. A large amount of debris was observed during CAS in four of the seven patients with CEUS-enhanced plaques that were also assessed as unstable on MRI, while two patients had a moderate amount and one patient had a small amount of debris. There were significant correlations between the amount of debris and plaque enhancement on CEUS, unstable plaque on MRI, and enhancement of plaque on CEUS with unstable plaque on MRI (p = 0.036, p = 0.029, p = 0.036, respectively). For the prediction of moderate to large amount of debris occurring in CAS, enhancement of plaque demonstrated by CEUS had a sensitivity of 66.7% and a specificity of 85.7%, unstable plaque determined by MRI had a sensitivity of 100% and a specificity of 42.9%, and enhancement of plaque by CEUS and unstable plaque determined by MRI had a sensitivity of 100% and a specificity of 75%.

Conclusion: Plaque vulnerability assessment using the combination of CEUS and MRI can predict the amount of debris retrieved during CAS, while using CEUS alone proved to be insufficient.

Objective: Due to the recent increase in the availability of cone-beam CT (CBCT), delineation of blood vessels and intracranial stents using CBCT has been well-reported, but reports using 3D-rotational angiography (3D-RA) have been few. We evaluated delineation of carotid artery stents using 3D-RA with diluted contrast medium.

Methods: We prepared simulated blood vessel phantoms covered by carotid artery stents different in material and shape. The phantoms were encapsulated with different concentration of contrast medium, and scanned using 3D-RA. The appropriate concentration of contrast medium was evaluated.

Results: The appropriate concentrations of diluted contrast medium were 50–17% for the Carotid Wall Stent (Boston Scientific, Natick, MA, USA) and 20%–10% for PRECISE (Johnson & Johnson, Miami, FL, USA) and PROTÉGÉ (Covidien, Irvine, CA, USA).

Conclusion: The appropriate concentration of contrast medium varied with carotid artery stent. By selecting an appropriate degree of dilution, the stent shape, plaque, intimal thickening, and vascular lumen in the stent can be visualized. Therefore, it is possible to evaluate vascular lumen after carotid artery stenting.

Objective: We discuss the details of a case in which iatrogenic vertebral arteriovenous fistula (VAVF) was successfully treated with a covered stent.

Case Presentation: A 62-year-old man presented with tinnitus after catheterization via the internal jugular vein and subsequently developed iatrogenic VAVF. Under general anesthesia, stent-assisted coil embolization was attempted via the right femoral artery but was unsuccessful. Therefore, a covered stent (Fluency 8 × 40 mm; C. R. Bard, Inc., Tempe, AZ, USA) was deployed, resulting in a marked decrease in shunt flow. The VAVF was obliterated 3.4 months after the procedure without postoperative complications.

Conclusion: Endovascular treatment using a covered stent can be an option for iatrogenic VAVF.

Objective: In cavernous sinus dural arteriovenous fistula (CSdAVF), multiple shunt points are often demonstrated on the angiogram. In some cases, shunt points may be located not only at the CS itself but at the part surrounding the CS. We report a rare case of CSdAVF with a shunt at the diploic vein of the orbital roof (DVOR).

Case Presentation: A 64-year-old man presented with exophthalmos, conjunctival injection, and abducens nerve palsy. The shunt points were suspected to be located at the anterior lateral part and posterior medial part of the left CS on the angiogram and the drainage route was the left superior ophthalmic vein (SOV) and the veins of the posterior fossa via the left petrosal vein. We embolized the suspected shunt points in the CS transvenously. Another shunt point was identified anterior to the CS by superselective angiography. By meticulous review of the angioarchitecture, using 3D rotational angiography and multi-planar reconstruction (MPR) images, another shunt point was found at the DVOR fed by branches of the ophthalmic artery and sphenopalatine artery branches.

Conclusion: We report a case of CSdAVF with multiple shunt points including a shunt located at the DVOR. To the best of our knowledge, this is the first case report with CSdAVF with a shunt point at the DVOR. In cases of CSdAVFs, careful analysis of the angioarchitecture using 3D rotational angiography, MPR images, and superselective angiography is necessary to elucidate the presence of shunts in rare locations.

Objective: Two cases of cerebral venous sinus thrombosis (CVST) effectively recanalized endovascularly by a combination of thromboaspiration using Cerulean catheter DD6 and stent retriever device are reported.

Case Presentations: We endovascularly treated two cases of CVST that presented with progressive vomiting and disturbance of consciousness several days before the diagnosis of occlusion of the main venous sinus and venous congestion. The thrombus was removed by the combined use of an aspiration system made of Cerulean catheter DD6 connected to the Penumbra aspiration pump and a Solitaire FR thrombectomy device. In one case, balloon thrombofragmentation was performed with local thrombolytic therapy. In both cases, the occluded venous sinus was recanalized, venous congestion was resolved, and early initiation of anticoagulation therapy was possible. After the procedure, neurologic symptoms disappeared, and both patients were discharged 16 days after the procedure with a modified Rankin Scale (mRS) score of 0.

Conclusion: In CVST, thromboaspiration by the concomitant use of a Cerulean catheter DD6 and a stent retriever is considered an effective therapeutic approach.

Purpose: We report a patient who underwent left carotid artery stenting (CAS) via the left brachial artery.

Case Presentation: The patient was a 71-year-old male with symptomatic stenosis of the left cervical internal carotid artery. He had undergone axillo-axillo bypass for occlusion of the right subclavian artery. He also had a history of arteriosclerosis obliterans of the bilateral lower limbs. A transbrachial approach was adopted. To increase the intensity of the flexible part of a Simmons-type guiding sheath, a guiding catheter was combined. The guiding sheath was guided/inserted into the left common carotid artery, and CAS was accomplished.

Conclusion: The combination of a Simmons-type guiding sheath and guiding catheter for increasing the intensity of the former’s flexible part was effective when inserting the guiding sheath into the left common carotid artery during left CAS via the left brachial artery.