Objective: The purpose of this study was to investigate the preventive effects of an eicosapentaenoic acid (EPA) medication on restenosis after carotid artery stenting (CAS).

Methods: Of 134 patients (144 episodes) who underwent CAS in our hospital or affiliated institutions between November 2005 and September 2017, the subjects were 123 who could be followed-up for ≥30 days after procedure by carotid ultrasonography with a mean age of 73.3 years (range: 55–90 years). Males accounted for 106 (86.2%) of the patients, 61 lesions (49.6%) were symptomatic. We retrospectively compared the incidence of restenosis between the two groups: EPA-treated group (n = 43) and non-EPA-treated group (n = 80). In addition, the serum levels of fatty acid compositions had been analyzed in 97 of the 123 patients, and the relationship of the EPA/arachidonic acid (AA) ratio with perioperative ischemic complications or restenosis was examined.

Results: There was no restenosis in any of the 43 EPA-treated patients, whereas it occurred in 8 (10%) of the 80 patients in the non-EPA-treated group, and the incidence of restenosis in EPA-treated group was significantly lower (p = 0.043) than that of non-EPA-treated group. In addition, the incidences of restenosis and perioperative ischemic complications were slightly higher in patients with a low EPA/AA ratio.

Conclusion: Although restenosis was more frequent in patients with a low EPA/AA ratio, the administration of an EPA medication may prevent restenosis in all patients who underwent CAS.

Objective: To clarify the usefulness and safety of neuroendovascular treatment with a 6 Fr guiding sheath via the right radial artery for anterior circulation lesions.

Methods: A total of 20 patients (carotid artery stenting: 11 patients, coil embolization of cerebral aneurysms: nine patients) who underwent neuroendovascular treatment via the right radial artery under general anesthesia, between September 2016 and June 2017, were included in this study. We retrospectively analyzed 1) the pertinent anatomy of the target-side common carotid artery and the aortic arch, 2) devices, 3) method to advance the guiding sheath into the common carotid artery, 4) hemostasis at the puncture site, and 5) outcome (success rate, perioperative complications, and complications at the site of puncture).

Results: In all patients, a 6 Fr guiding sheath could be guided into the common carotid artery, and treatment was accomplished. Furthermore, there was no perioperative or puncture-site complication.

Conclusion: Transradial neuroendovascular treatment is considered as a safe and successful choice for anterior circulation lesions.

Objective: We report two cases of non-sinus-type dural arteriovenous fistula (dAVF) cured by transarterial embolization (TAE) alone.

Case Presentations: Case 1: A 55-year-old male presented with tinnitus and MRI showed dilated abnormal vessels and a varix in the right frontal lobe. Angiograms revealed a right parasagittal dAVF, supplied by the bilateral frontal branch of middle meningeal artery (MMA) without direct drainage into the superior sagittal sinus (SSS). Case 2: A 62-year-old male presented with headache and hemianopia and CT showed intracranial hemorrhage in the right occipital lobe. Angiograms revealed a vault dAVF located at the right occipital convexity, supplied by the squamous branch of the right MMA and the mastoid branch of the occipital artery (OA) without direct drainage into the transverse sinus.

In both cases, we performed TAE with low-concentration n-butyl-2-cyanoacrylate (NBCA) injected from wedged catheters via the MMA and dAVFs were completely disappeared.

Conclusion: In selected cases, transarterial NBCA embolization is a safe, curative method to address dAVF.

Objective: Many vertebral arteriovenous (AV) fistulae are associated with trauma. Recently, a procedure to embolize a fistula and parent blood vessel by endovascular treatment has been performed as standard treatment. We report a patient in whom stent-assisted coil embolization with the preservation of the vertebral artery (VA) led to the disappearance of a fistula.

Case Presentation: A 48-year-old male. He complained of pulsatile tinnitus 5 days after head bruise. Detailed examination showed a left extracranial vertebral AV fistula with reflux into the intracranial space. Dilation of the AV fistula was noted, with the venous pouch surrounding the VA. Stent-assisted coil embolization of the fistula through the venous side was performed, reducing blood flow. The disappearance of the AV fistula was confirmed 3 months after surgery.

Conclusion: We encountered a patient in whom stent-assisted coil embolization of a traumatic vertebral AV fistula led to its disappearance. As a method to preserve a parent blood vessel, stent-assisted treatment may be effective.

Objective: We report two patients with a rapid increase in the ocular pressure after carotid artery stenting (CAS) for cervical internal carotid artery stenosis with ocular ischemic syndrome.

Case Presentations: Case 1 was a 67-year-old male. Case 2 was a 70-year-old male. In the two patients, a reduction in vision and transient hemiparesis had persisted for a few months, leading to a diagnosis of severe internal carotid artery stenosis. Furthermore, they were diagnosed with ocular ischemic syndrome and neovascular glaucoma. Panretinal photocoagulation was performed before CAS in the Department of Ophthalmology. In Case 1, ocular pain appeared 9 days after CAS. In Case 2, it appeared the day after CAS, and increased ocular pressure was noted. After conservative treatment, trabeculectomy was performed, but the visual prognosis was unfavorable.

Conclusion: In patients with severe internal carotid artery stenosis and ocular ischemic syndrome, there may be a rapid increase in the ocular pressure after revascularization. Therefore, it is necessary to establish a cross-sectional treatment strategy in cooperation with ophthalmologists.

Objective: We describe a case of de novo dural arteriovenous fistula (dAVF) developed after bilateral neck clipping for middle cerebral artery (MCA) aneurysms, treated with transarterial embolization (TAE) using liquid materials.

Case Presentation: A 60-year-old man underwent neck clipping for a right ruptured MCA aneurysm, and a left unruptured MCA aneurysm. Follow-up MRA 1 year after the clipping showed an abnormal enlarged bilateral occipital artery (OA). Onyx was partially penetrated to parasinus, but low-concentration n-butyl-2-cyanoacrylate (NBCA) was widely penetrated to parasinus. After that, developed memory disturbance gradually worsened. The angiography demonstrated dAVF at transverse sinus, sigmoid sinus (SS), sinus confluence, and superior sagittal sinus with numerous cortical venous reflux. He was treated with TAE with liquid in two sessions. After embolization, cortical venous reflux completely disappeared and his cognitive dysfunction could be rapidly resolved. One year after the treatment, the angiogram revealed no recurrence of cortical venous reflux and he could maintain his independence.

Conclusion: In this case, bilateral craniotomy for neck clipping caused “de novo” dAVF presenting with cognitive dysfunction. In addition, TAE using NBCA was very useful to cure multiple dAVF.

Objective: To increase procedure-related options for Pipeline Embolization Device (PED) insertion.

Case Presentation: An 83-year-old female patient with a right internal carotid artery (ICA) cerebral aneurysm in the cavernous sinus being on follow-up showed subsequently an increase in the aneurysmal size and diplopia, and surgery was considered. Diagnostic cerebral angiography showed marked arteriosclerosis, and it was difficult to guide selectively a catheter into the ICA. Therefore, for treatment, we planned PED insertion by direct puncture of the carotid artery through direct cervical surgical exposure. Under general anesthesia, a cervical skin incision exposed the common carotid artery. Surgical vessel holding tapes were placed distal and proximal to the site to be punctured on the common carotid artery. Using a pediatric puncture kit, a 4 Fr sheath was inserted in the common carotid artery. Next, under fluoroscopy the ICA was entered using a 0.035-inch guidewire that was exchanged for a 6 Fr Destination 90-cm (Terumo Corporation, Tokyo, Japan) long. This was carefully guided into the ICA. Subsequently, a PED measuring 5 × 35 mm was inserted to the aneurysmal site using a 5 Fr Navien 115 cm (Marksman; Covidien, Irvine, CA, USA). Hemostasis by suture was performed at the site of arterial puncture. There were no intraoperative or postoperative complications.

Conclusion: Direct puncture of the carotid artery can be an effective method for patients in whom it may be difficult to insert a PED due to arteriosclerosis.

Objective: Carotid artery stenting (CAS) for common carotid artery stenosis via the transfemoral approach might have a potential risk of iatrogenic distal embolism. In this study, we present a technique of transradial stenting with 6 Fr modified Simmonds guiding sheath for stenosis of the common carotid artery.

Case Presentations: A 6 Fr modified Simmonds guiding sheath was introduced via the right radial artery and advanced to the common carotid artery without passing a guidewire or coaxial catheter through the stenotic lesions. Two cases with common carotid artery stenosis were treated successfully with this procedure.

Conclusion: Transradial CAS with modified Simmonds guiding sheath provides a safe and durable alternative option for patients with common carotid artery stenosis having vulnerable plaques.