Objective: All physicians should endeavor to perform safe and rapid neuroendovascular operations. We describe the process of identifying novel methods and highlight some representative clinical examples from our practice.
Methods: We made a habit of asking questions regarding problems encountered during operations. Potential solutions are often identified and noted in our smartphones or as memos. These solutions are then evaluated by experiments in vascular models before assessing their efficacy in clinical settings.
Results: Some ideas based on our process of raising problems and finding solutions were published, and found to be relevant to the wider scientific community. Moreover, all ideas were applicable in most settings due to the use of conventional, familiar, and cheap methods and equipment. The paper rail method, modified pigtail shape microguidewire, microcatheter in vivo printing method, microcatheter shaping cast, and wireless trans-cell approach are presented as representative ideas.
Conclusions: We reported methods of neuroendovascular therapy identified through the routine practice of problem-solving by our team.
Objective: To retrospectively analyze the complication rates and risk factors associated with the use of the Angio-Seal vascular closure device during neuroendovascular therapy.
Methods: In this study, we enrolled 283 patients who underwent Angio-Seal hemostasis between December 2005 and June 2019 at our institute. We retrospectively analyzed the major and minor complication rates and risk factors between the complication and no-complication groups using the medical charts of patients for whom the device was used.
Results: Of the 283 patients, 5 had major complications (1.8%) and 18 had minor complications (6.3%). There were no significant differences between the complication (n = 23) and no-complication (n = 260) groups regarding the baseline characteristics or operation procedures. Among the major complications, superficial femoral artery puncture, 8Fr device, Angio-Seal Evolution, post-carotid artery stenting, dual antiplatelet therapy, and delirium were considered risk factors.
Conclusion: The Angio-Seal is a safe and useful hemostatic device. However, puncture site complications need to be considered when the device is used for contraindicated patients or for those with delirium who cannot rest following the procedure.
Objective: We report a case of dissecting aneurysm developed after traumatic vertebral artery dissection (VAD) treated by stenting combined with coil embolization.
Case Presentation: A 47-year-old man was injured in a fall and presented with left VAD associated with central spinal injury due to C2 fracture. One week after admission, magnetic resonance imaging (MRI) demonstrated contralateral VAD with a dissecting aneurysm. Due to bilateral VAD, we employed coil embolization and stenting for the dissecting aneurysm to prevent rupture and embolic events, and to maintain the patency of the dominant right VA. There were no complications during the perioperative period. The follow-up angiogram 6 months after embolization confirmed obliteration of the dissecting aneurysm and patency of the parent artery.
Conclusion: Stenting combined with coil embolization is an effective treatment for traumatic VAD with a dissecting aneurysm.
Objective: There is no established method for carotid artery stenting (CAS) for internal carotid artery stenosis with vulnerable plaque and thrombosis. We report a case in which CAS was performed by aspiration using the Penumbra system for thrombosis that increased in the subacute phase in symptomatic cervical internal carotid artery stenosis.
Case Presentations: A 59-year-old man with a history of lacunar infarction visited the emergency department with weakness in the right upper limb. He was admitted for cerebral infarction in the left corona radiata and basal ganglia. During the course, additional multiple cerebral infarctions developed in the left cerebral hemisphere. The patient was diagnosed with left internal carotid artery stenosis and underwent CAS. As mural thrombus increased compared with preoperative imaging, CAS was performed after thrombus aspiration using the Penumbra system. A large amount of plaque was observed in the aspirated blood.
Conclusion: Thrombus aspiration using the Penumbra system was effective as distal embolic protection during CAS for internal carotid artery stenosis with increased and shape-changing thrombus. The aspirated blood exhibited pathological findings of plaque tissue and thrombus.
Objective: The authors report the first case of intracranial fibromuscular dysplasia (FMD) presenting with rapid de novo formation of an unruptured large vertebral artery (VA) fusiform aneurysm.
Case Presentation: A 41-year-old man presented with left hemiparesis. He had a giant thrombosed aneurysm at the basilar artery-superior cerebellar artery (BA-SCA) junction and a left extracranial VA aneurysm. A de novo VA fusiform aneurysm developed during a 1-month interval following the first session of intravascular coil embolization for the BA-SCA aneurysm. Stress on the fragile artery due to FMD during micro-catheterization may have caused the de novo aneurysm. An anomalous aortic origin of the left VA may also have played a role in the formation of the large de novo aneurysm and extracranial VA aneurysm. We performed overlapping stent-assisted coil embolization for the VA fusiform aneurysm using an Enterprise VRDs, and coil embolization for the BA-SCA thrombosed aneurysm using the stent-assisted technique with an Enterprise stent. Both aneurysms remained occluded for 7 years.
Conclusion: We concluded micro-catheterization to be the cause of the large de novo aneurysm. This case emphasizes the importance of carefully performing intravascular interventional procedures for patients with FMD.
Objective: We report a novel technique for acute occlusion of both intracranial and extracranial arteries (tandem lesions [TL]).
Case Presentation: A 67-year-old male was transferred to our hospital because of right hemiparesis and aphasia. MRA revealed occlusion of the left cervical internal carotid artery (ICA) and middle cerebral artery (MCA). A balloon guide catheter (BGC) was advanced into the left common carotid artery (CCA). A microcatheter was advanced over a microwire through the intracranial thrombus. A stent retriever (SR) was deployed from the MCA to the ICA through the microcatheter. Next, with the SR anchored to the thrombus, the microcatheter was withdrawn. The extracranial percutaneous transluminal angioplasty (PTA) balloon was coaxially advanced over the SR’s delivery wire and angioplasty was performed. Then, an aspiration catheter was coaxially advanced to the proximal aspect of the intracranial thrombus over the delivery wire by pump aspiration. We removed the SR and the aspiration catheter as a single unit into the BGC, resulting in sufficient recanalization. The puncture to recanalization time was 29 minutes.
Conclusion: This technique can lead to faster recanalization in cases of TL.