Intraprocedural plaque protrusion resulting in cerebral embolism during carotid angioplasty with stenting.

An 82-year-old man with an asymptomatic left high-grade carotid stenosis was treated with carotid artery stenting (CAS) under distal protection. The procedure consisted with predilation with a 5 x 40 mm percutaneous transluminal angioplasty (PTA) balloon, deployment of a 10 x 20 mm self-expandable stent, post-dilation with a 7 x 20 mm PTA balloon, and aspiration of debris with 60 ml of blood. The cervical carotid angiogram immediately after deflation of the distal blocking balloon demonstrated a small in-stent filling defect of the contrast medium that protruded from the anterior wall of the carotid artery. The following cranial carotid angiogram showed abrupt occlusion of the left middle cerebral artery (MCA). Because the in-stent lesion had vanished in the repeat study after recognition of this embolic event, it was suggested that an embolus had been liberated from the in-stent lesion, reaching the left MCA and obliterating it. In this case, the embolus was speculated to originate in the ruptured plaque, which protruded into the stent through the cells of the device and became liberated into the bloodstream. Attention should be paid so as not to overlook any plaque protrusion, which may be seen subsequently as a cerebral embolism on the angiogram obtained immediately after CAS.

Shortening of Wallstent RP during carotid artery stenting requires appropriate stent placement.

Changes in the location and length of the Wallstent RP during carotid artery stenting (CAS) were evaluated using intraoperative videos of 28 patients with carotid artery stenosis who underwent CAS with a 10/20 mm Wallstent RP to determine the appropriate stent placement. The stent was deployed after its midpoint was positioned over a virtual center line, the perpendicular line which crossed the most stenotic point of the lesion on the road mapping image. The length of the stenotic lesion, the changes in the locations of the distal and proximal ends of the stent, and the changes in stent length were examined. The distal end of the stent moved a maximum of 6.1 mm toward the proximal side to a point 19.9 mm from the virtual center line. The proximal end moved a maximum of 11.3 mm toward the distal side to a point 14.7 mm from the virtual center line. The stent length ranged from 37.7 to 44.5 mm (mean 41.2 mm). The 10/20 mm Wallstent RP placed by our technique covers the entire lesion with no less than 5.7 mm of margin over the segment distal to the lesion in patients with stenotic segments shorter than 29.4 mm.

Symptomatic inferior cavernous sinus artery aneurysm associated with cerebral arteriovenous malformation.

A 50-year-old man presented with a symptomatic aneurysm arising from the right inferior cavernous sinus artery (ICSA) associated with a cerebral arteriovenous malformation (AVM) manifesting as a 3-month history of progressive right abducens nerve palsy. Cerebral angiography demonstrated a high-flow AVM and a saccular aneurysm arising from the right ICSA acting as a meningeal feeder. The symptom was thought to be attributable to aneurysmal mass effect rather than the AVM. The aneurysm was successfully treated with endovascular embolization and the symptom improved gradually. Hemodynamic stress in the ICSA may have resulted in the development of the aneurysm of the ICSA. Meningeal artery aneurysm presenting with cranial nerve palsy is extremely uncommon. The present case illustrates the need for detailed evaluation of the external carotid artery and internal carotid artery vasculature in patients with cerebral AVMs.

Endovascular treatment of tiny ruptured anterior communicating artery aneurysms.

INTRODUCTION: Because of its high complication rate, the endovascular treatment (EVT) of anterior communicating artery (ACoA) aneurysms less than 3 mm in maximum diameter remains controversial. We evaluated EVT of tiny ruptured ACoA aneurysms with Guglielmi detachable coils (GDCs). METHODS: We treated 19 ruptured ACoA aneurysms with a maximum diameter of

Development of unusual collateral channel from the posterior meningeal artery after endovascular proximal occlusion of the posterior inferior cerebellar artery.

A 38-year-old man presented with a dissecting aneurysm of the left proximal posterior inferior cerebellar artery (PICA) manifesting as Wallenberg's syndrome. The patient was treated by endovascular occlusion of the aneurysm and parent artery. Immediately after the treatment, the PICA territory was supplied by collateral circulation via the ipsilateral anterior inferior cerebellar artery. Seven days later, endogenous revascularization of the distal PICA territory had occurred via collateral circulation from the posterior meningeal artery (PMA). This unusual collateral circulation was thought to occur through a pre-existing anastomotic channel between the primitive vessels of the PICA and the PMA during subclinical hypoperfusion of the distal PICA territory. This unusual case demonstrates the potential for delayed development of collateral circulation from the PMA to the PICA territory.

Spasm induced by protection balloon during carotid artery stenting.

PURPOSE: The PercuSurge system is a distal balloon embolic protection device used for carotid artery stenting (CAS). We performed a retrospective study on the prognosis and clinical effects of spasms induced by the PercuSurge GuardWire system (PercuSurge-induced spasm). MATERIALS AND METHODS: We performed CAS in 118 carotid stenoses using the PercuSurge system. Of the 118 procedures, 31 (26.3%) of the patients experienced PercuSurge-induced spasm, and all underwent postoperative follow-up studies by cerebral angiography and antiplatelet treatment. RESULTS: On follow-up angiograms obtained a mean of 5.2 months (range 3-10 months) after CAS, all 31 PercuSurge-induced spasms had disappeared, and no delayed stenosis was found at the sites where the spasms had occurred. No ischemic events due to the spasms occurred during a mean follow-up of 13 months (range 3-32 months). CONCLUSION: In the hands of physicians experienced in endovascular surgery, CAS using the PercuSurge system is a safe method with which to treat patients with carotid stenosis. Our study demonstrated that PercuSurge-induced spasms had no morphological or clinical adverse effects.

[Clinical efficacy of blood flow interruption using the HyperForm in right vertebral arteriovenous fistula--case report].

A 44-year-old male with right vertebral arteriovenous fistula accompanied with tinnitus, underwent endovascular treatment using GDC. A digital subtraction angiography clearly showed one fistula flowed from the right vertebral artery (VA) to the vertebral venous plexus, while the right VA close to the fistula was interupped with HyperForm. The tip of the micro catheter was placed in the vertebral venous plexus through fistula from the right VA, and the vertebral venous plexus around the fistula was embolized with 4 GDCs. Blood flow of the right VA was maintained. Follow-up angiography undertaken 6 months after the operation didn't show the recurrence of arteriovenous fistula.

Cerebral protection during retrograde carotid artery stenting for proximal carotid artery stenosis: technical note.

Carotid artery stenting for carotid bifurcation stenosis usually uses the transfemoral approach. However, in patients with proximal common carotid artery (CCA) stenosis, the guiding catheter is difficult to introduce into the narrow origin of the CCA without risking cerebral embolization before activation of the protection device. A technique of cerebral protection by internal carotid artery (ICA) clamping with or without simultaneous external carotid artery (ECA) clamping was used to treat patients with proximal CCA stenosis by the retrograde direct carotid approach. The carotid bifurcation was surgically exposed and retrograde catheterization was performed to approach the stenosis. The ICA was clamped during angioplasty and stenting to avoid cerebral embolization. The ECA was clamped simultaneously if any extracranial-intracranial anastomosis was present. None of five patients treated with this technique experienced ischemic complications attributable to this technique.

Accordion effect during carotid artery stenting: report of two cases and review of the literature.

INTRODUCTION: The term "accordion effect" is used to describe a mechanical distortion of tortuous arteries mimicking spasm or dissection. This phenomenon has been reported in patients undergoing percutaneous coronary intervention. To our knowledge, this is the first documentation of the accordion effect during carotid artery intervention. METHODS: Two patients who developed the accordion effect during carotid artery stenting (CAS) are described. RESULTS: Angiograms obtained just after CAS showed a stenosing lesion with wall irregularity at the distal part of the stent. This lesion disappeared and tortuosity of the internal carotid artery developed after withdrawing the guidewire until its floppy segment rested equally on the lesion. In another patient, the lesion did not disappear completely until the guiding catheter had been withdrawn to the proximal portion of the common carotid artery. We conclude that these stenosing lesions reflected the accordion effect. CONCLUSION: It is essential to differentiate the accordion effect from dissection, spasm, and thrombosis because the management is importantly different. We report our findings and present a review of the literature.

Stent fracture in revascularization for symptomatic ostial vertebral artery stenosis.

INTRODUCTION: We assessed the long-term follow-up examinations and complications of percutaneous transluminal angioplasty and stenting (PTAS) for symptomatic ostial vertebral artery (VA) stenosis. METHODS: A retrospective study was done to evaluate 12 patients with symptomatic ostial VA stenosis who underwent PTAS. Six patients were treated with the Palmaz stent and six with a balloon-expandable coronary stent. Initial angiographic follow-up examination was conducted about 12 months after PTAS in all patients. Simple radiographic, ultrasonographic and clinical follow-up examinations were scheduled every 6 months. RESULTS: Excellent dilatation was achieved in all patients without any procedural complications. Initial angiographic follow-up obtained at a mean of 13 months after PTAS detected no restenosis. However, an asymptomatic severe restenosis was detected at 24 months after PTAS in one patient (8%). During a mean follow-up of 31.5 months, three stent fractures were detected in deployed coronary stents (50%). None of the stent fractures was associated with either recurrent stroke or restenosis. No patients developed recurrent symptoms during the follow-up period. CONCLUSION: PTAS for symptomatic ostial VA stenosis is effective in preventing recurrent stroke. As the open-cell single-joint type of stent is associated with the risk of fracture, long-term follow-up examinations including simple radiography are needed.

Hyperform remodeling balloon for the balloon occlusion test of persistent primitive trigeminal artery aneurysm - case report.

A 17-year-old woman presented with a rare aneurysm at the junction of the persistent primitive trigeminal artery (PPTA) and the internal carotid artery (ICA) manifesting as left abducens nerve paresis. The aneurysm and the ICA were both successfully occluded with coils. The balloon occlusion test used the HyperForm balloon microcatheter to seal the PPTA and ICA, which is very important to determine the optimal treatment strategy for a PPTA aneurysm.

Percutaneous reconstruction of the innominate bifurcation using the retrograde 'kissing stents' technique.

INTRODUCTION: Obstructions of the supraaortic vessels are an important cause of morbidity associated with a variety of symptoms. Percutaneous transluminal angioplasty has evolved as an effective and safe treatment modality for occlusive lesions of the supraaortic vessels. However, the endovascular management of an innominate bifurcation has not previously been reported. METHODS: A 53-year-old female with a history of systematic hypertension, diabetes mellitus and hypercholesterolemia presented with left hemiparesis and dysarthria. Angiography of the innominate artery showed a stenosis of the innominate bifurcation. RESULTS: The lesion was successfully treated using the retrograde kissing stent technique via a brachial approach and an exposed direct carotid approach. CONCLUSION: The retrograde kissing stent technique for the treatment of a stenosis of the innominate bifurcation was found to be a safe and effective alternative to conventional surgery.

Hemodynamic stability under general anesthesia in carotid artery stenting.

PURPOSE: The purpose of our study was to investigate the frequency of hemodynamic instability in patients undergoing carotid artery stenting (CAS) under general anesthesia using sevoflurane and nitrous oxide in oxygen. METHODS: A total of 97 consecutive CAS procedures were performed in 84 patients under sevoflurane anesthesia. The following hemodynamic variables were assessed: degree of systolic blood pressure change (deltaSBP) during CAS, hypotension, and bradycardia during and after CAS. RESULTS: During CAS, hypotension occurred in 43% of the patients, and bradycardia occurred in 14%. There was individual variation in the deltaSBP during CAS. Systolic blood pressure (SBP) change >50 mmHg was not seen in this series. After CAS, hypotension occurred in 24%, and bradycardia occurred in 10%. Cerebral infarction occurred in three cases. The stroke rate was 3.1% in this series. CONCLUSION: General anesthesia using sevoflurane and nitrous oxide in oxygen depressed barorecepter reflex sensitivity, induced hemodynamic stability under CAS, and may decrease the rate of occurrence of complications.