Object: We report initial results of our experiences in stent-assisted coil embolization for unruptured cerebral aneurysms using the Enterprise vascular reconstruction device (VRD). Method: Retrospective analysis of the clinical and angiographic results, complications and outcomes was performed on 31 consecutive patients during the period between July 2010 and May 2011. Result: The patients (8 male and 23 female) were on average 62.2 years old (range 42-83). Twenty aneurysms were in the anterior circulation (internal carotid artery 18, anterior communicating artery 2), and 11 were in the posterior circulation (posterior cerebral artery 1, basilar artery 6, vertebral artery 4). In 31 aneurysms, 26 were the saccular type and 5 were the fusiform type. Mean diameter of the aneurysms was 12.5±5.2 mm. The jailing technique was used in 8 cases and balloon-assisted technique in 23 cases. The angiographic result of embolization was complete occlusion in 5 (16.2%), neck remnant in 25 (80.6%), and body filling in 1 (3.2%). The average volume embolization rate was 29.3±9.0%. Two patients (6.5%) presented transient ischemic attack in the post-treatment period, though both of them showed complete recovery without any permanent morbidity. Conclusion: Our initial experiences reveal that stent-assisted coil embolization using the Enterprise VRD appears useful in the treatment of certain cases of wide-neck aneurysm, which are intractable by conventional endovascular techniques, though a long-term follow-up is mandatory to prove its actual usefulness.
Background: The 3.3Fr catheter is reported as a useful tool for less invasive cerebral angiography. However, this catheter has not been widely used because it is considered difficult to manipulate. We herein report our assessment of two types of 3.3Fr catheters that have been newly developed for cerebral angiography. Materials and methods: The two types of newly developed 3.3Fr catheters (3.3Fr-A and 3.3Fr-B) and the existing one (3.3Fr-C) were compared to the conventional 4Fr catheter with regard to the following parameters: torque transmission, trackability, and kink resistance. Result: The 3.3Fr-A catheter had inferior torque transmission, similar trackability, and superior kink resistance compared with the 4Fr catheter. On the other hand, the 3.3Fr-B catheter had superior torque transmission, inferior trackability, and similar kink resistance compared with the 4Fr catheter. Furthermore, the 3.3Fr-C catheter was inferior to the 4Fr catheter in terms of all three parameters, and also inferior to both 3.3Fr-A and 3.3Fr-B catheters. Conclusion: The newly developed 3.3Fr catheters may be useful for cerebral angiography because their maneuverability is expected to be similar to that of 4Fr catheters.
Objective: Straightening of the coil at its proximal end is rare but possible. We report a case of internal carotid aneurysm in which this phenomenon was encountered during parent artery occlusion. Case presentation: A 69-year-old woman underwent endovascular trapping of an unruptured left cavernous internal carotid artery (ICA) aneurysm, 15mm in diameter. Three coils were deployed with incomplete occlusion, and a segment of the ICA distal to the aneurysm remained to be occluded. Therefore, an additional coil (ED coil, extrasoft type, 5mm in diameter, 10cm in length; Osaka, Japan) with a diameter larger than the diameter of the ICA was introduced. After smooth insertion of the first part, the remaining 3cm part of the coil became considerably less flexible. The straightened coil was detached without further modification. Thereafter, endovascular trapping was completed in the standard manner without any technical problems and complications. Conclusion: The straightening of the coil may occur due to the shortening of stretch resistant (SR) filaments. This shortening is due to excessive widening of the pitch of the primary coil following insertion into a cavity that is smaller in diameter than the diameter of the secondary loop of the coil. This phenomenon seemed to arise in our patient because the inserted coil, which was larger than the diameter of the ICA, became folded too compactly.
Objective: We report the successful coil embolization of an isolated dissecting aneurysm of the lateral medullary segment of the left posterior inferior cerebellar artery (PICA). Case presentation: A 61-year-old woman presented with sudden severe headache and transient loss of consciousness. On admission, Hunt and Hess grade IV subarachnoid hemorrhage was diagnosed. Cerebral angiography showed an isolated dissecting aneurysm of the lateral medullary segment of the left PICA and she underwent coil embolization. Although she manifested bilateral abducens nerve palsy on the first post-treatment day, after 3 weeks this improved to mild left abducens nerve palsy. Conclusion: Coil embolization may be a reliable treatment alternative to surgery in patients with isolated dissecting aneurysms of the PICA.
Objective: A case of carotid artery stenosis treated with carotid artery stenting (CAS) using the Carotid Wallstent, in which the stent covering the internal carotid artery (ICA) migrated into the common carotid artery (CCA) due to shortening, is reported. Case presentation: A 74-year-old man with asymptomatic carotid artery stenosis (the diameters of the ICA and CCA: 6.5mm and 10.3mm, respectively) was treated with CAS using the Carotid Wallstent and FilterWire EZ. The stent was deployed to cover the distal ICA and extended into the CCA. However, coverage of the distal normal ICA was insufficient due to the tortuosity of the distal ICA. Final angiography revealed successful stent coverage of the distal normal ICA and entire lesion. The 3D-CT angiogram on the third postoperative day demonstrated stent migration into the CCA due to the shortening of the Carotid Wallstent and residual stenosis of the ICA. Therefore, a Precise stent was deployed using the PercuSurge GuardWire protection system to cover the ICA. Conclusions: In cases of CAS using the Carotid Wallstent, we should be alert to possible shortening and migration of the stent, especially if the lesion contains a tortuous ICA and the CCA diameter is large.
Objective: In-stent thrombosis following carotid artery stenting (CAS) is a devastating complication. We report a rare case of repeated in-stent thrombosis with a complicated clinical course. Case presentation: A 68-year-old male with bilateral internal carotid artery stenosis underwent right CAS without any complications. Repeated postoperative stent occlusions developed due to in-stent thrombosis at postoperative day 5, 10, 14 respectively after left CAS, which was performed 2 months after the right CAS. The thrombosis occurred repeatedly despite endovascular treatments including clot disruption / aspiration / intraarterial urokinase infusion / angioplasty / stenting and maximized pharmacotherapy including dual antiplatelet therapy and anticoagulation using heparin / warfarin. The patient eventually developed an intracerebral hemorrhage at day 17. Conclusion: Prolonged antithrombotic therapy for post-procedure repeated in-stent thrombosis may increase the risk of intracranial hemorrhage. Early aggressive surgical treatment including carotid endarterectomy and removal of the stent should be considered in this situation.
Objective: We report a case of cerebral infarction caused by distal embolism during carotid artery stenting (CAS) using the FilterWire EZ (FWEZ) protection device. Case presentation: A 78-year-old man with a history of right cerebral infarction was treated with CAS for bilateral progressive carotid artery stenosis. The FWEZ distal embolic protection device was used during the procedure. Although no complications occurred after CAS on the right side, symptomatic cerebral infarction occurred after CAS on the left side. Angiography revealed no flow in the left carotid artery after CAS. Materials retrieved from the FWEZ device included yellowish debris. Magnetic resonance imaging revealed acute cerebral infarction in the left cerebral hemisphere. Conclusion: This is the first report, to the authors'knowledge, of the no flow phenomenon during CAS using the FWEZ protection device. It is important to recognize that the use of a filter-type distal embolic protection device (even if it is an excellent device such as the FWEZ) cannot exclude the possibility of no flow after CAS.
Objective: We report a case of unruptured large aneurysm associated with persistent primitive trigeminal artery (PTA) treated by endovascular trapping after balloon test occlusion (BTO) with tandem balloons. Case presentation: A 37-year-old woman presented with diplopia and ptosis due to left oculomotor palsy. Cerebral angiography revealed a left PTA and unruptured large aneurysm at the junction of the PTA and the left internal carotid artery (ICA). The left carotid angiogram showed filling of the upper basilar artery via the PTA, and the left vertebral angiogram also showed filling of the basilar artery and entire posterior circulation. To evaluate the tolerance for the aneurysm trapping, we performed BTO with tandem balloons placed both proximal and distal to the aneurysm to isolate the left anterior circulation from both the ICA and PTA. As the mean stump pressure was below 60% of pre-BTO value, left superficial temporal artery-middle cerebral artery anastomosis was performed a week before endovascular trapping. Subsequently, the aneurysm, ICA, and PTA were successfully embolized with coils, leading to completion of trapping of the aneurysm, without causing any new neurological deficits. Conclusion: To evaluate the precise hemodynamics and collateral circulation, BTO using tandem balloons seems to be useful in cases of persistent PTA.