Object: This report describes our initial experience using a new self-expanding nitinol stent, Enterprise VRD (Cordis, Miami, FL, USA), designed for the treatment of wide-necked intracranial aneurysms.
Method: Stent-assisted coiling was performed in 33 wide-necked saccular aneurysms between July 2011 and December 2012 in this institution. Six aneurysms were recanalized after prior endovascular treatment. The aneurysms were located in the following arteries: 15 internal carotid artery (ICA; 45.5%), 2 middle cerebral artery (MCA; 6.1%), 3 anterior communicating artery (AcomA; 9.1%), 12 basilar artery (BA; 36.7%), 1 posterior cerebral artery(PCA; 3.0%). The mean aneurysm dome size was 11.6 mm (7-25 mm), the mean aneurysm neck size was 6.54 mm (4-13.8 mm). Patients were given 81 mg of aspirin and 75 mg of clopidogrel daily starting at least 7 days before stent deployment. All stents were deployed using the standard jailing technique.
Result: The stent was accurately placed in all patients. Difficulty in navigating the Prowler Select Plus microcatheter (Cordis, Miami, FL, USA) beyond the aneurysm neck was experienced in 5 patients (15.2%). Therefore, catheter exchange was performed in these patients. Slip drop of the Prowler Plus during the stent deployment occurred in 1 patient. Additional coil embolization immediately after stent deployment was achieved in all patients, and occlusion was complete in 25 patients (75.8%). However, it was necessary to switch from the jailed technique to the trans-cell technique in 8 patients (24.2%). Procedural adverse events included two thrombo-embolisms and one subarachnoid hemorrhage. There was a 3% morbidity rate and no mortality. Follow-up angiography was achieved in 10 patients. Asymptomatic stent occlusion occurred in 1 patient.
Conclusion: The Enterprise VRD is valuable in the treatment of wide-necked aneurysms. However, its safety and efficacy should be further evaluated in a larger series with longer follow-up.

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Objective: To evaluate the feasibility and safety of carotid artery stenting (CAS) via the transradial approach (TR-CAS).
Materials and Methods: Among the 157 CAS patients (180 lesions) treated at our department from 2005 to 2011, a total of 6 patients underwent TR-CAS. We evaluated the technical success and periprocedural and access-site complications of this procedure retrospectively. First, we inserted a 4 Fr sheath into the right radial artery, then infused spasmolytic agents, and replaced the 4 Fr sheath with a 6 Fr guide sheath.
Results: The reasons to use the transradial approach were "bovine" arch (the left carotid artery originating in the brachiocephalic trunk) in 2 patients, abdominal aortic aneurysm in 3 patients (fusiform or dissecting), and bilateral femoral vascular prostheses in 1 patient, respectively. In both of the cases of "bovine" arch, it was relatively easy to place the tip of the guide sheath into the common carotid artery on the affected side. Conversely, in the other 4 cases, stiff or extra-stiff guidewires were needed to place the tip of the guide sheath appropriately. TR-CAS was successfully performed in 5 cases (83%) without any complications. In a case with right carotid stenosis, TR-CAS could not be performed and resulted in a periprocedural stroke. There were no access-site complications in any of these cases.
Conclusion: TR-CAS appears to be a useful alternative to CAS candidates that are unsuitable for the transfemoral approach.

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Objective: We report a case of hearing disturbance occurring as a rare complication of transvenous embolization of a dural arteriovenous fistula (AVF) involving the anterior condylar confluence (ACC).
Case presentation: A 61-year-old man presented with hearing disturbance after transvenous embolization of a dural AVF involving the ACC. The manifestations of the dural AVF were left ocular symptoms such as conjunctival injection, chemosis, and diplopia. An angiogram located the fistula in the left ACC. And the ACC dural AVF was supplied mainly by the left ascending pharyngeal artery and drained from the ACC into the left inferior petrosal sinus, cavernous sinus, and superior ophthalmic vein retrogradely. It had no other drainage pathway angiographically. We attempted but failed to advance a microcatheter into the fistula at the ACC by the transvenous approach. Therefore we inserted the microcatheter into the left inferior petrosal sinus (IPS) and occluded the left IPS (the only available drainage route from the ACC) with platinum detachable coils. The final angiogram revealed almost no AVF remained. Soon thereafter left ocular symptoms improved, however, a left neurosensory hearing disturbance appeared 3 days later. The hearing disturbance was treated with steroid therapy and systemic heparinization immediately but was unresponsive to this treatment.
Conclusion: The hearing disturbance may be due to venous circulatory failure of the inner ear after occlusion of the IPS. The fistula, and not the IPS, should be occluded in the treatment of ACC dural AVF to avoid hearing complications.

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Objective: We report a case of giant cervical paravertebral arteriovenous shunt (AVS) with multiple dural arteriovenous fistulas (dAVFs) at the C1-2 cervical level successfully managed with embolization.
Case presentation: A 47-year-old male presented with progressive myelopathy and mild heart failure. Workup imaging studies indicated a giant cervical paravertebral arteriovenous shunt with soft tissue arteriovenous malformation (AVM) suggesting a diagnosis of spinal arteriovenous metameric syndrome (SAMS). Numerous feeding arteries contributed to these lesions and the shunt volume was extremely large. Transarterial and transvenous embolization of this huge paraspinal AVS did not improve his symptoms. The finding of multiple dAVFs located at the C1-2 cervical space on follow-up angiography after the 11th session led to the suspicion that these dAVFs were responsible for his myelopathy. His symptoms improved after the treatment of these dAVFs.
Conclusion: Precise diagnosis of the lesion responsible for the main symptom is mandatory in the treatment of complex spinal AVS, such as occurs in SAMS.

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Objective: We report a rare case of left middle cerebral artery embolism due to fibromuscular dysplasia (FMD) in the cervical internal carotid artery.
Case presentation: A 47-year-old female presented with motor aphasia and right hemiparesis. MRI showed early ischemic changes in the left frontal lobe and insular cortex. Cervical MRA showed irregularity of the vessel wall in the left cervical internal carotid artery and occlusion of the left middle cerebral artery (MCA). Because the patient was ineligible for intravenous recombinant tissue plasminogen activator, we chose endovascular therapy for recanalization. A left common carotid angiogram demonstrated typical findings of FMD and occlusion extending from the distal M1 to M2 segment of the MCA. Therefore, we performed balloon catheter disruption of the thrombus without thrombectomy using a Merci retriever. The occluded MCA was successfully recanalized and good clinical outcome was obtained.
Conclusion: We considered that the left MCA occlusion was caused by artery-to-artery embolism derived from FMD. This is the first report of balloon catheter disruption of the thrombus due to FMD.

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Objective: We report a case of central retinal artery embolization just after carotid artery stenting (CAS).
Case presentation: A 74-year-old man presented with severe asymptomatic right internal carotid artery stenosis. After informed consent was given, CAS was performed for stenosis of the right internal carotid artery using distal filter and flow reversal devices. Immediately after CAS, the patient complained of blurred vision in the right eye. The following day, right fundoscopy revealed ischemic retinal whitening and a fluorescein angiogram showed no filling of the retinal arteries. One month later, examination revealed no improvement in right visual acuity and visual field defect.
Conclusion: Central retinal artery embolization during CAS is rare but should be kept in mind as a serious complication even when embolic protection (including use of a flow reversal method) is provided.

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Objective: We report a case of cavernous sinus dural arteriovenous fistula (CdAVF) completely occluded by targeted embolization using coils.
Case presentation: A 30-year-old woman presented with left chemosis and ipsilateral exophthalmos. MRI showed left CdAVF. Angiographic examination showed a dural arteriovenous fistula at the left anterior compartment of the cavernous sinus supplied mainly by the accessory meningeal artery and draining mainly into the left superior ophthalmic vein. Endovascular treatment was performed using the transarterial approach. A microcatheter was advanced into the accessory meningeal artery. Superselective angiography demonstrated the fistula point at the inferolateral wall of the cavernous sinus. Placement of coils from the microcatheter to the fistulous point resulted in complete occlusion of the fistula and immediate improvement in the patient's symptoms.
Conclusion: Targeted transarterial embolization using coils may be the best treatment treatment option for select cases of CdAVF.

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Objective: We report a case of left common carotid artery stenting in which the guide sheath was held in place by a GooseNeck Snare inserted from the right brachial artery.
Case presentation: A 70-year-old man presented with transient right hemiparesis and symptomatic left common carotid artery stenosis. During carotid artery stenting, we were unable to insert the guide sheath into the distal site of the carotid artery because of the short distance between the origin of the carotid artery and the stenotic lesion. By holding the guide sheath in place using the GooseNeck Snare inserted from the right brachial artery, stenting was performed successfully.
Conclusion: Transbrachial GooseNeck Snare was useful for stabilization of the guide sheath during left common carotid artery stenting.

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Objective: The ED Coil Inifini® (Kaneka, Osaka, Japan) features a large loop design and excellent flexibility to provide better embolization within an irregularly shaped cavity. The authors report two cases of direct carotid-cavernous fistula (direct CCF) treated using an endovascular approach with the ED Coil Inifini®.
Case presentation: Case 1: An 83-year-old woman presented with direct CCF manifesting as sudden-onset right pulsatile tinnitus. After the failure of transarterial embolization and transvenous embolization via the inferior petrosal sinus, a transvenous embolization from the facial vein via the superior ophthalmic vein was planned. We failed to occlude the fistula point using other ED coils. Subsequently, we used the ED Coil Inifini® and achieved a complete occlusion of the fistula point. Recanalization was not detected at 8 months after the treatment. Case 2: A 72-year-old woman presented with a direct CCF manifesting as sudden-onset right pulsatile tinnitus. Placement of the ED Coil Inifini® was performed via the transarterial and transvenous approaches. Although a mild shunt flow persisted, a favorable outcome was obtained. All the patients' symptoms disappeared after the treatment.
Conclusion: The ED Coil Inifini® expands in irregularly shaped spaces and can occlude an affected cavernous sinus even when the catheter cannot be navigated into the fistula point. Our cases demonstrated the usefulness of ED Coil Inifini® for the treatment of direct CCF.

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