Objective: Debranching thoracic endovascular aortic repair (TEVAR), in which endovascular stent-grafting with cervical vascular reconstruction for aortic aneurysm arch lesion is increasing, and these cases have difficulties in access during neuroendovascular treatment. In this study, we investigated the selection of appropriate access route according to the methods of debranching TEVAR during neuroendovascular treatment.

Methods: We examined a zone classification of aortic lesion, the number of debranch, and vascular reconstruction techniques of debranching TEVAR and assessed an optimal access route for each debranching TEVAR reconstruction method.

Results: Four patients underwent neuroendovascular treatment after debranching TEVAR. Aortic lesion of each patient located in zone 0 in 1 patient, zone 1 in 2 patients, and was unclassifiable in 1 patient. Total debranching was performed in 1 case, 2 cases of 2-debranching, and 1 case of 1-debranching with chimney reconstruction. The pathologies treated included 1 unruptured basilar artery aneurysm, 1 direct carotid cavernous fistula, 1 subclavian artery aneurysm, and 1 acute basilar artery occlusion.

The access routes selected were the brachial artery approach in 3 cases and direct puncture of right common carotid artery in 1 case. Optimal access route selection for each method of debranching TEVAR resulted in no complications associated with the access route and technical success in all cases.

Conclusion: With the expansion of indications for debranching TEVAR, opportunities for neuroendovascular treatment of these patients will increase. Physicians need to be aware of the problems of access routes for neuroendovascular treatment in patients with debranching TEVAR.

Objective: The aim of this study was to evaluate the relationships between approach time and anatomical factors of the aortic arch in endovascular therapy. Whether 2D images of plain computed tomography (2DCT) could provide imaging information about the aortic arch equivalent to those of contrast-enhanced three-dimensional computed tomography angiography (3DCTA) was also investigated.

Methods: A retrospective review of our institutional database was performed to identify 65 patients who underwent endovascular treatment via the femoral artery and 3DCTA between January 2017 and June 2019. The anatomical factors of the aortic arch were evaluated, including the angle between the target vessel and the aortic arch (apex, inferior margin) and the distance from the apex of the aortic arch to the target vessel on 2DCT and 3DCT. The relationships between patients' characteristics and the procedure were investigated. The approach time was defined as the time from puncture to target angiography after guiding catheter placement.

Results: The average approach time was 24.4 minutes. On 2DCT and 3DCTA measurements, the correlation coefficients with the distance from the apex of the aortic arch to the target vessel (r=0.858) and with the angle between the target vessel and the inferior margin of the aortic arch (r=0.721) were strong. The approach time was linearly correlated with the distance from the apex of the aortic arch to the target vessel (r=0.478). In addition, the approach time was negatively correlated with the angle between the aortic arch and the target vessel (r=−0.197), and a stronger correlation was observed for the angle between the target vessel and the inferior margin of the aortic arch (r=−0.298).

Conclusion: The 2D images of plain CT can provide imaging information about the aortic arch equivalent to those of 3DCTA. The approach time becomes longer when the distance from the apex of the aortic arch to the target vessel is long or when the angle between the inferior margin of the aortic arch and the target vessel is acute.

Objective: We report a case of aplastic or twig-like middle cerebral artery (Ap/T-MCA) with a tiny ruptured aneurysm in the collateral network in a patient who presented with intracerebral hemorrhage that was treated using bypass surgery and parent artery occlusion.

Case Presentation: A 51-year-old man presented with a headache. CT revealed intracerebral hemorrhage in the right temporal lobe, and CTA revealed Ap/T-MCA. He received conservative therapy; however, he developed rebleeding on the 10^th day of admission. DSA revealed a tiny ruptured aneurysm in the collateral vascular network between the anterior choroidal and anterior temporal arteries. We performed initial bypass surgery, followed by parent artery occlusion using a liquid embolic agent for treatment of the aneurysm.

Conclusion: The treatment strategy should consider the site of hemorrhage, including the collateral network and the patient's hemodynamics in case of Ap/T-MCA hemorrhage.

Objective: Craniocervical junction arteriovenous fistula (CCJ-AVF) is a very rare vascular malformation, and its pathophysiology, natural course, and optimal treatment strategy have not been clearly elucidated. We report a case of CCJ-AVF that occurred with subarachnoid hemorrhage and was completely treated by transarterial embolization.

Case Presentation: A 61-year-old-man presented with severe subarachnoid hemorrhage. Cerebral angiography showed a CCJ-AVF and a small aneurysm on the feeder from the anterior spinal artery, which was the origin of the hemorrhage. The fistula and the feeder aneurysm were occluded completely by transarterial embolization with n-butyl cyanoacrylate (NBCA).

Conclusion: The arteriovenous system around the CCJ is extremely complicated, necessitating a thorough understanding of the detailed vascular anatomy of CCJ and precise interpretation of angiographic findings before determination of the treatment strategy.

Objective: We report a case of carotid artery stenting (CAS) using intraoperative monitoring for carotid artery stenosis with contralateral carotid occlusion (CCO).

Case Presentation: A 68-year-old man underwent CAS for progressive left carotid artery stenosis with CCO, and the plaque images demonstrated plaque vulnerability. Therefore, we chose to perform a temporary carotid occlusion by distal balloon protection with monitoring (SEP and NIRS) before the procedure. If we did not confirm ischemic tolerance, we would have used a distal filter protection device. Monitoring demonstrated ischemic tolerance for a short time during the procedure with the occluded internal carotid artery at the cervical segment instead of the petrous segment. We performed CAS with distal balloon protection.

Conclusion: Monitoring may be useful for CAS in patients with CCO.

Objective: Limb shaking is an aparoxysmal symptom of transient ischemic attack in patients with high-grade occlusive diseases of the internal carotid artery or Moyamoya disease. We report a rare case of limb shaking seen during carotid artery stenting (CAS) using distal balloon protection in a patient with symptomatic carotid stenosis.

Case Presentation: A 68-year-old woman presented with repeated transient right hemiparesis. Single photon emission computed tomography (SPECT) revealed low perfusion in the left hemisphere owing to the left carotid stenosis and poor collaterals. She was treated with CAS using distal balloon protection. During the procedure, she developed involuntary movement on the right upper and lower limbs. This involuntary movement disappeared after deflation of the protective balloon. A further reduction in the left cerebral blood flow due to balloon protection during CAS seemed to have caused the limb shaking.

Conclusion: An appropriate strategy for CAS that considers limb shaking as an ischemic symptom in patients with preoperative ipsilateral hypoperfusion is needed.

Objective: We have experienced two cases of recanalization using EmboTrap II in patients with cervical internal carotid artery dolichoarteriopathy.

Case Presentation: Case 1, 36-year-old man, developed embolic stroke of undetermined sources, with occlusion of the left internal carotid artery in a 360-degree loop, which was initially treated with closed-cell stent retrievers and finally recanalized by EmboTrap II. In Case 2, 73-year-old female, cerebral embolism was associated with infective endocarditis, and the left internal carotid artery with S-shaped tortuous neck was occluded and recanalized after a single pass by EmboTrap II.

Conclusion: The EmboTrap II is a two-layered and segmented design that allows for effective acute revascularization of tortuous internal carotid arteries due to dolichoarteriopathy.

Objective: Herein, we report a case of multiple dural arteriovenous fistulas (DAVFs) in the left superior petrosal sinus (SPS) successfully treated by transvenous embolization via the right SPS.

Case Presentation: A 60-year-old woman was diagnosed with multiple DAVFs with deep venous reflux to evaluate consciousness disturbance. We performed packing of the left transverse sinus, which was chiefly involved in reflux to the straight sinus. However, consciousness continued to be mildly disturbed, and DSA was performed again. A shunt was inserted into the left SPS, and the subsequently occurring deep venous reflux was clearly revealed. Because the ipsilateral transverse sinus and both inferior petrosal sinuses were already occluded and unavailable as access routes, we used the contralateral SPS and both cavernous sinuses to navigate the microcatheter into the shunt. We achieved occlusion of the SPS and stopped the reflux by inserting the intermediate catheter firmly into the bilateral SPS.

Conclusion: An access route through the contralateral SPS might successfully enable transvenous embolization of DAVF cases without an ipsilateral access route.