Objective: To compare clinical results of carotid artery stenting (CAS) under distal protection with the use of Angioguard XP and PercuSurge GuardWire.
Methods: 138 patients treated by CAS under distal protection from September 2002 to November 2008 were included in this study. 85 patients treated with GuardWire were divided into 2 sequential groups, the early GW group (n=42) and the late GW group (n=43). Angioguard XP was used in 53 patients (the AG group) from November 2007. Treatment results from the 3 groups were investigated.
Results: A stent was successfully deployed in all patients. 1 patient in the early GW group died of intracerebral hemorrhage which developed 5 days after CAS. In the late GW group, 1 patient died of multiple organ failure after intraoperative abdominal wall hemorrhage and another patient showed persistent hemiparesis due to intracerebral hemorrhage which occurred 1 week after CAS. Procedure-associated learning curve was not demonstrated between the 2 groups. In the AG group, postoperative MRI diffusion-weighted imaging disclosed new high-intensity lesions in the area of the treated carotid artery in 7 patients, in which 2 patients suffered from thromboembolic strokes.
Conclusion: Hemorrhagic complications were causes of disability for patients treated with GuardWire. Thromboembolic events were more frequently encountered in patients undergoing CAS with Angioguard XP.

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Objective: Carotid artery stenting (CAS) using a filter-type distal protection device (F-DPD) allows minimal interruption of blood flow and might be useful for patients with inadequate collateral circulation. The present study examines the feasibility and safety of CAS using F-DPD rather than carotid endarterectomy (CEA) for carotid vascular reconstruction in patients with internal carotid stenosis accompanied by contralateral internal carotid occlusion (ICO-ICS).
Method: The study included 17 consecutive patients with ICS-ICO (mean age 69 years, all males). Carotid plaques were evaluated using black-blood MRI and diagnosed as "soft plaque" when the relative overall plaque signal was ≥ 1.25 on T1-weighted images. As a general rule, CAS using F-DPD was performed for ICS-ICO and CEA was considered only when soft plaque was identified. Preoperative examinations, peri-procedural complications, and the occurrence of restenosis were analyzed retrospectively.
Results: Vascular reconstruction by either CAS (13 patients) or CEA (4 patients) was adequate in all patients with ICS-ICO. The relative overall plaque signal was 1.14 ± 0.36 in CAS group and 1.48 ± 0.22 in CEA group, respectively. Two of 3 CAS operations using a balloon-type DPD to treat patients with soft plaque proceeded under general anesthesia because of insufficient ischemic tolerance. Although we did not confirm any symptomatic ischemic complications, all three of these patients had asymptomatic high-signal spots on post-operative diffusion weighted images (DWI). High-signal lesions on DWI emerged in the contralateral hemispheres in 2 patients after CAS using F-DPD. Slow-flow and no-flow did not arise during any CAS procedures using F-DPD. Post-procedural prolonged hypotension and bradycardia were evident in 3 patients after CAS. Restenosis (> 50%) did not arise in patients during an average follow-up period of 12 months after both CAS and CEA.
Conclusion: With proper selection of patients based on plaque characterization and meticulous measures against periprocedural hypotension, CAS using F-DPD as a first line procedure is feasible, safe and effective.

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Purpose: To review the clinical outcome of endosaccular coil embolization for intradural aneurysms presenting oculomotor nerve palsy.
Materials and Methods: We treated 6 cases of intradural aneurysms presenting oculomotor nerve palsy. There were 4 cases of subarachnoid hemorrhage and 2 cases of non-ruptured aneurysms. The aneurysms were located at 4 internal carotid-posterior communicating artery (IC-PC) in 4 cases, internal carotid-anterior choroidal artery (IC-AchoA) in another and at basilar artery-superior cerebellar artery (BA-SCA) in the other. The size of the aneurysms ranged from 5.8 to 8.7 mm. Four cases presented complete oculomotor nerve palsy, and 2 cases incomplete.
Results: Complete recovery from oculomotor nerve palsy was achieved in 4 cases and partial recovery in 2 cases. Two cases with pre-operative incomplete oculomotor nerve palsy recovered completely. To facilitate recovery from oculomotor nerve palsy, loose packing of the aneurysmal bleb was intentionally performed in selected cases.
Conclusion: In spite of persistent anatomical contact or close proximity of the aneurysm to the oculomotor nerve, endosaccular coil embolization is an effective treatment in comparison to surgical clipping. The presence of the pre-operative oculomotor nerve palsy does not influence the selection of the clipping or coiling treatment methods.

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Objective: We report a rare case of an ascending pharyngeal-internal jugular arteriovenous fistula (AP-IJ AVF).
Case presentation: A 32-year-old woman was admitted with a 5-year-history of pulsatile tinnitus. Left external carotid angiography demonstrated a single-hole AVF between the ascending pharyngeal artery and the superior bulb of the internal jugular vein. The fistula was completely occluded by transarterial embolization using detachable coils. The patient showed immediate improvement after embolization.
Conclusion: AP-IJ AVF is considered a subgroup of parachordal AVFs. Transarterial embolization is an effective treatment for this condition.

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Objective: A case of cavernous sinus dural arteriovenous fistula (dAVF) with bone erosion is reported.
Case presentation: A 69-year-old female presented with pulsatile tinnitus and diplopia. Cerebral angiography showed multiple fistulas in bilateral cavernous sinuses and a venous pouch adjacent to the left cavernous sinus with venous drainage into bilateral superior ophthalmic veins, as well as cortical venous reflux into the superficial middle cerebral and cerebellar veins. 3-dimensional dynamic CT revealed early filling of bilateral cavernous sinuses, and coronal multi-planar reconstruction images in the bone window demonstrated bone erosion on the dorsum sellae adjacent to the venous pouch. We considered that the bone erosion was caused by both the venous pouch and related vessels of the dAVF. Transvenous coil embolization resulted in disappearance of the dAVF.
Conclusion: The proximity of bone erosion to both fistulous points and venous pouch provided useful adjunctive information regarding angioarchitecture of dAVF and thus facilitated transvenous embolization.

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Objective: Percutaneous transvenous embolization (TVE) of a transverse/sigmoid sinus dural arteriovenous fistula (TS/SS dAVF) through the mastoid emissary vein (MEV) is reported.
Case presentation: A 46-year-old man was admitted to our hospital for cerebral venous infarction. Angiography revealed left TS/SS dAVF with isolated sinus and retrograde cortical venous reflux. Transarterial embolization resulted in successful reduction of the shunt flow and improvement of the clinical symptoms. Transvenous approach through the occluded dural sinus into the affected sinus failed. Direct puncture of the dilated occipital vein was then performed, and TVE using coils was performed successfully through the MEV. This procedure resulted in complete disappearance of the dAVF.
Conclusion: This technique is a simple and good alternative treatment in patients for whom conventional approach to the isolated sinus is difficult to adopt, if there is the drainage of the dilated mastoid emissary vein.

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Purpose: To report a case of carotid artery dissection after carotid endarterectomy (CEA) successfully treated with carotid artery stenting (CAS).
Case presentation: A 64-year-old man with cerebral infarction and central retinal artery occlusion due to left proximal internal carotid artery stenosis was treated with CEA. Postoperative MRA and 3D-CTA demonstrated asymptomatic carotid artery dissection. The entry point of the dissection was located 1 cm distal to the distal edge of the endarterectomy, where puncture with a 24-G needle for measuring stump pressure measuring was performed. Carotid artery dissection became prominent on 3D-CTA after 3 months. CAS with Angioguard XP / PECISE stent was performed. Complete repair of the carotid artery dissection was achieved.
Conclusion: CAS offers a safe and effective treatment for post-endarterectomy carotid dissection. 3D-CTA is useful for 3-dimensional evaluation of carotid artery dissection. A distal protection filter device, which allows intraoperative angiography, is useful for accurate positioning of the stent.

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Objective: To report two cases of a giant extracranial cervical carotid artery pseudoaneurysms treated with covered stents.
Case presentation: Case 1: A 72-year-old man receiving palliative care for stomach cancer presented swelling in the neck and a hoarse throat. Angiogram revealed a pseudoaneurysm with a diameter of 5 cm in the cervical carotid artery. The guiding catheter was introduced through the common carotid artery exposed surgically at the neck. A covered stent was placed over the ostium of the pseudoaneurysm. Because endoleak occurred, a bare stent was overlapped inside the covered stent. The final angiogram showed successful exclusion of the pseudoaneurysm. Case 2: A 71-year-old woman with advanced gastric cancer presented neck pain and dyspnea. Angiogram revealed a pseudoaneurysm with a diameter of 6 cm in the cervical carotid artery. A covered stent was placed over the ostium of the pseudoaneurysm. The following day's angiogram showed re-opacification of the aneurysm due to slip drop of the covered stent. Inserting a bare stent and an additional covered stent successfully excluded the aneurysm.
Conclusion: Endovascular treatment with a covered stent is a safe and effective treatment for giant cervical carotid artery pseudoaneurysms.

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