Objective: Clinical research demonstrating safety and security in subclavian artery stenting (SAS) is limited because treatment strategies for SAS vary greatly among institutions, operators, and clinical conditions, as no standard protocol exists. As stenotic lesions frequently occur in the proximal portion of the subclavian artery (SA), it is often difficult to stabilize the guiding catheter for stent delivery. Our purpose was to assess whether lesion location can be used to predict optimal procedural strategies.

Methods: We performed a retrospective, single-center observational study on 26 consecutive patients who underwent SAS between 2004 and 2016. We categorized patients treated with SAS into two groups according to lesion location: those with lesions located less than 10 mm from the origin of the SA (Group P) and those with lesions in the distal portion (Group D). We defined a bidirectional approach via both brachial and femoral puncture as well as bilateral brachial puncture as combined access. In pull-through method, a guidewire was passed from one sheath to another. We compared Group P with Group D in terms of procedural strategy and efficacy.

Results: All 26 cases were clinically successful. Asymptomatic cerebral embolism was found in 10 (48%) of 21 cases in which postoperative MRI was performed, and the number of spotty lesions was less than four in every patient. Arterial access-site complications were documented in eight patients. Two cases of late in-stent restenosis were retreated with balloon dilatation. Cases with retrograde ipsilateral vertebral artery (VA) blood flow and symptomatic lesions occurred more frequently in Group P than in Group D (79% vs. 42%; p = 0.06, 71% vs. 33%; p = 0.05, respectively). Patients in Group P were significantly more often treated with combined access (100% vs. 42%; p = 0.001), with the pull-through method (64% vs. 0%; p < 0.001) than those in Group D. The distal end of the stent was involved with the ipsilateral VA orifice more often in Group D than in Group P (50% vs. 7%; p = 0.02).

Conclusion: These results demonstrate that our strategy is a safe and effective method of stenting for SA stenosis in the portion of the artery that is proximal to the aorta. We should pay special attention to the risk of arterial access-site complications.

Objective: It is essential to improve the in-hospital system and arrangement to achieve recanalization as soon as possible in acute cerebral artery occlusion. In Saitama Prefecture, the stroke emergency transport system began to operate in January 2018 under the prefectural government initiative. At our hospital, also, a trial aiming at rapid, safe, and effective recanalization was initiated in August 2017 in a team consisting mainly of doctors and co-medical staff of the Stroke Center. In this report, the results of the 17-month trial are reviewed.

Methods: In all, 127 patients with acute cerebral artery occlusion who underwent endovascular treatment between January 2016 and December 2018 (56 treated before and 71 treated after the initiation of the time-reducing trial) were compared. Interdepartmental conferences and simulations were frequently held with participation primarily by physicians, radiology technicians, and nurses, and information about treatments, operations by various professionals, and therapeutic approaches was shared. The diagnostic and therapeutic processes of the cases experienced were also promptly evaluated and modified for improvements.

Results: The time from the arrival of the patient to the injection of recombinant tissue plasminogen activator (rt-PA) was significantly reduced from 90 to 75 minutes, time from the arrival to puncture from 99 to 74 minutes, procedure time from 63 to 50 minutes, and time from the arrival to eventual recanalization from 165 to 130 minutes. The rate of effective recanalization was higher after the initiation of the trial (62% vs. 76%), but the difference was not significant. The percentage of patients with a favorable outcome was also higher after the initiation of the trial (25% vs. 39%).

Conclusion: The results of this study indicate that the time of emergency treatment for acute cerebral artery occlusion can be shortened even in a large-scale university hospital with many constraints by sharing of information among departments and making sure that the medical staff of stroke center is well-informed of the standardized therapeutic approach.

Objective: A method to create a microcatheter with a short and acute-angled tip using an Excelsior SL-10 pre-shaped S catheter (Stryker, Kalamazoo, MI, USA) by straightening its proximal curve is described. Its clinical application, in which a guidewire and a microcatheter are led into a distal artery branching sharply to prepare stent deployment, is presented.

Methods: The proximal curve of a catheter was introduced into a disposable 18-gauge blunt needle. The needle was heated using a heat gun so as to heat and straighten only the proximal curve and to preserve the original shape and firmness of the distal curve. The catheter was then used to lead a guidewire to a sharply branching distal artery and subsequently to navigate itself into the artery. In each case, the angle formed by the vector of the proximal parent artery and that of the distal artery was measured to evaluate the technical difficulty. The usefulness of the catheter was assessed by whether stenting was completed.

Results: The microcatheter was used in 10 cases. The average angle between the distal artery and the proximal parent artery was 144°. In two cases where the angle was over 180°, the guidewire could not enter the orifice of the distal artery directly. The guidewire could directly enter the orifice of the distal branch in eight cases, with angles of 108°–151°. In seven of the eight, the guidewire and microcatheter could go further into the distal artery, and stenting was achieved.

Conclusion: A short and acutely angled catheter tip made from an Excelsior SL-10 pre-shaped S catheter with preservation of the distal curve is stable in shape. It is often useful when leading a guidewire to an artery branching at a sharp angle to prepare for stent-assisted coiling.

Objective: We show our experiences with the use of a 6Fr Cerulean DD6 (Medikit, Tokyo, Japan) catheter and represent the availability of DD6.

Methods: Between May 2017 and October 2018, we performed 19 neurointerventional procedures for 17 patients of anterior circulation aneurysms and two neurointerventional procedures for two patients of posterior circulation aneurysms. We validated the results of the procedures with DD6 such as the techniques of coil embolization, the positions of DD6, the related complications, the kickbacks of DD6, and so on.

Results: In all cases, we succeeded with the placement of DD6 and there were no related complications and kickbacks of DD6. The positions of DD6 were C3 in six cases, C4 in 8, C5 in 5, V3 in 1, and V4 in 1. Of all procedures, 12 were performed with the balloon assist technique, 5 were with the stent assist technique, and 4 were with the simple technique.

Conclusion: Utilizing DD6, the access difficulty of cervical vessels is apparently reduced and the maneuvers of microcatheters can be made much safer and more reliable for neurointerventional procedures.

Objective: To examine a case of basilar artery (BA) occlusion caused by traumatic vertebral artery (VA) dissection after incomplete endovascular therapy.

Case Presentation: A 32-year-old man who got caught sustained injuries in a truck accident wherein he was stuck between two trucks was transported to a nearby hospital. Stenting was performed for the left common carotid artery (CCA). For left VA dissection, coil embolization of the VA was performed to prevent thromboembolic infarction because floating thrombus was found at the V3 segment. On postoperative day 1, he exhibited conscious disturbance. MRA revealed BA occlusion. Upon transfer to our hospital, thrombectomy was performed. After revascularization, the patient was alert.

Conclusion: Although optimal treatment of traumatic VA injury is still debated, proximal coil occlusion is regarded as an effective preventive treatment for thromboembolic stroke. In case of VA dissection with floating thrombus, proximal VA occlusion is insufficient to prevent thromboembolic stroke, and thrombus capture should be considered.

Objective: In this report, we describe a case of cervical vertebral arteriovenous fistula (AVF) associated with neurofibromatosis type 1(NF1) presented as radiculopathy.

Case Presentation: A 65-year-old female patient diagnosed with left cervical vertebral artery lesion-like aneurysms and NF1 incidentally. After 5 years, she presented with neck pain and left upper weakness. Examinations revealed left vertebral AVF. Endovascular therapy was performed and her symptoms were improved.

Conclusion: Endovascular therapy should be performed if asymptomatic cervical vertebral aneurysms associated with NF1 are growing or become symptomatic.