Utility of a Steerable Microcatheter for the Selective Transvenous Embolization of Dural Arteriovenous Fistulas.

Objective: Selective transvenous embolization (sTVE) is an effective technique for treating dural arteriovenous fistulas (DAVFs); however, selective catheterization into the shunted pouch is often difficult due to the acute angle of the access route between the target pouch and dural sinus. We present our initial experience using a steerable microcatheter (SM) to manually control the tip angle for selective catheterization and sTVE of DAVFs. Methods: Thirteen consecutive cases of DAVFs and 16 procedures that involved sTVE using SM between October 2016 and October 2018 were reviewed. SMs were used for selective catheterization of shunted venous pouches and/or the affected sinus and coil embolization. We evaluated the maneuverability of the SM, the success of selective catheterization into the target lesions, and the results of endovascular treatments. Results: Endovascular procedures were performed in a single session in 10 cases and in two staged sessions in 3 cases. There was no difficulty in maneuverability of the SM. Successful selective catheterization was achieved in 26 of 27 target lesions. Immediately after embolization, angiography showed complete occlusion in 10 cases and marked reduction in 3 cases. During 40.9 months of mean follow-up, 12 cases showed complete occlusion and one case showed a small residual shunt on MRI. Procedure-related complications of spontaneous thrombosis of the affected sinus were observed in one case. There were no cases of recurrence or exacerbation during follow-up. Conclusion: SM is useful for selective catheterization for target lesions during sTVE of DAVFs.

Arterial Administration of DNA Crosslinking Agents with Restraint of Homologous Recombination Repair by Intravenous Low-Dose Gemcitabine Is Effective for Locally Advanced Pancreatic Cancer.

(1) Background: Pretreatment by Rad51-inhibitory substances such as gemcitabine followed by arterial chemotherapy using antineoplastic agents causing DNA crosslink might be more beneficial for patients with locally advanced pancreatic cancers than conventional treatments. The efficacy of arterial administration of DNA crosslinking agents with pretreatment of intravenous low-dose gemcitabine for patients with unresectable locally advanced or metastatic pancreatic cancer (LAPC or MPC) is evaluated. (2) Methods: A single-arm, single-center, institutional review board-approved prospective study was conducted between 2005 and 2015. Forty-five patients (23 LAPC, 22 MPC) were included. Patients received a weekly low dose of gemcitabine intravenously for three weeks followed by arterial administration of mitomycin C and epirubicin hydrochloride at tumor-supplying arteries on the fifth or sixth week. This treatment course was repeated at 1.5-to-2-month intervals. Overall survival (OS), local progression-free survival (LPFS), and therapeutic response were evaluated. LAPC or MPC were divided according to treatment compliance, excellent or poor (1 or 2), to subgroups L1, L2, M1, and M2. (3) Results: OS of LAPC and MPC were 23 months and 13 months, respectively. The OS of LAPC with excellent treatment compliance (subgroup L1, 10 patients) was 33 months with 31 months of LPFS, and four patients (40%) had a complete response (CR). The OS of the L1 subgroup was significantly longer than those of other subgroups L2, M1, and M2, which were 17 months, 17 months, and 8 months, respectively. As Grade 3 adverse effects, severe bone marrow suppression, interstitial pneumonitis, and hemolytic uremic syndrome were observed in six (13.0%), three (6.5%), and three (6.5%) patients, respectively. (4) Conclusions: Arterial DNA crosslinking with the systemic restraint of homologous recombination repair can be a new treatment option for LAPC.

Selective transvenous embolization combined with balloon angioplasty of the occluded inferior petrosal sinus for the treatment of cavernous sinus dural arteriovenous fistulas.

BACKGROUND AND PURPOSE: Angioplasty of the dural sinus has rarely been performed for the treatment of cavernous sinus dural arteriovenous fistulas. We evaluated the efficacy of selective transvenous embolization (TVE) combined with balloon angioplasty of the occluded inferior petrosal sinus (IPS) for the treatment of cavernous sinus dural arteriovenous fistulas (CSDAVFs). MATERIALS AND METHODS: A total of 8 consecutive patients with CSDAVFs with occlusion of the IPS treated by selective TVE with balloon angioplasty of the IPS from July 2018 to January 2019 were retrospectively reviewed. There were 6 females and 2 males with an average age of 77.6 years. All patients showed ocular symptoms. Angiography showed cortical venous reflux in 7 cases and localized shunted pouches at the medial portion of the cavernous sinus, intercavernous sinus, or laterocavernous sinus. Selective TVE was performed via the occluded IPS with bilateral femoral venous approaches, and the occluded IPS was reconstructed by angioplasty with a 2- to 3-mm diameter balloon during or after selective TVE. RESULTS: CSDAVFs disappeared immediately after treatment, and the occluded IPSs were successfully reconstructed with re-establishment of normal antegrade venous flow in all cases. No complications were observed, and symptoms resolved within 2 weeks after treatment. During the 7-month mean follow-up period (range 1-12 months), no cases showed recurrence of CSDAVFs. CONCLUSION: Selective TVE combined with balloon angioplasty of the occluded IPS is safe and effective for the treatment of CSDAVFs and re-establishes normal venous circulation in selected cases with localized shunted pouches.

Investigating Signal Loss due to a Carotid Artery Stent in 3D-TOF-MRA.

PURPOSE: In this study, we investigated the factors of signal loss out because of the presence of a stent and optimized imaging parameters for improvement in depiction ability. METHODS: We investigated the relationship between the stent type and magnetic susceptibility effect by measuring the signal value between the inside and outside of the stent with different Bw and TE for two different kinds of stents respectively. Similarly, flip angles were changed for two different kinds of stents respectively to the signal intensity between the inside and the outside of the stent was measured, in which examine the relationship between the stent type and the Ernst angles in RF-shielding effect. The conventional imaging parameters and the optimum imaging parameters for each stent obtained from the result of the phantom experiment were examined. Optimized 3D time-of-flight MR angiography (3D-TOF-MRA) was performed and compared with conventional 3D-TOF-MRA and computed tomography angiography (CTA). RESULTS: The influence of the magnetic susceptibility effect is small in the central part of Carotid Wallstent and in PRECISE, and large in the Carotid Wallstent at the both ends. The influence of RF-shielding effect was large at PRECISE, where the Ernst angle was greatly shifted while the effect is no longer influenced at Carotid Wallstent. Both Carotid Wallstent and PRECISE made imaging capability improved by optimizing the imaging parameters. CONCLUSION: During clinical imaging of patients post-carotid artery stenting (CAS) using our protocol, the ability to visualize blood vessels was improved. Thus, we demonstrated that the ability of 3D-TOF-MRA post-CAS was improved via optimizing imaging parameters.

Fusion imaging using subtracted and unsubtracted rotational angiography for pretherapeutic evaluation of dural arteriovenous fistulas.

PURPOSE: We describe the clinical utility of an imaging technique that combines 3D subtracted and unsubtracted rotational angiography for evaluation of the angioarchitecture of dural arteriovenous fistulas (DAVFs). METHODS: From May 2010 to June 2013, 21 consecutive patients with intracranial DAVFs (22 lesions) underwent 3D angiography for pretherapeutic evaluation. 3D fusion angiography (3DFA) images were semiautomatically obtained from a dataset of unsubtracted and subtracted rotational angiographs. Multiplanar reformatted images and partial MIP images from unsubtracted rotational angiography and fusion images were evaluated by two radiologists, with particular focus on visualization of feeding arteries, shunted pouches, and drainage veins of DAVFs by use of a 3-point scale. The referring neuroradiologists were asked whether the information provided by 3DFA was helpful for treatment decisions. RESULTS: For 21 of 22 lesions, all evaluated items were well depicted on the 3DFA. The visualization rating score for feeding arteries and shunted pouches on 3DFA were significantly higher than those of 3D digital angiography (p < 0.05). There were no statistically significant differences between visualization of drainage veins. The information provided by the fusion images was helpful for treatment decisions in all cases. CONCLUSION: 3DFA images are useful for evaluation of the angioarchitecture of intracranial DAVFs.

Anatomical variations in termination of the uncal vein and its clinical implications in cavernous sinus dural arteriovenous fistulas.

INTRODUCTION: The aim of the study was to investigate the variations in the uncal vein (UV) termination and its clinical implication in cavernous sinus dural arteriovenous fistulas (CSDAVFs). METHODS: Biplane cerebral angiography in 80 patients (160 sides) with normal cerebral venous return (normal group) was reviewed with special interest in the termination of the UV. Frequency and types of uncal venous drainage from CSDAVFs in consecutive 26 patients were also analyzed. RESULTS: In the normal group, the UV was identified in 118 sides (74 %). The UV terminated into cavernous sinus (CS) in 41 sides (34 %), the superficial middle cerebral vein (SMCV) in 58 sides (48 %), the laterocavernous sinus (LCS) in 15 sides (13 %), and the paracavernous sinus (PCS) in 4 sides (3 %). Cerebral venous blood via the UV draining into the CS directly (n=41) or through the SMCV and/or the LCS (n=45) was observed in 86 sides (54 %). Uncal venous drainage from CSDAVFs was found in 13 patients (50 %). The CSDAVFs drained directly into the UV in two patients, drained via LCS into the UV in two patients, and drained through the SMCV into the UV in the remaining nine patients. All cases were successfully treated by transvenous embolization with special attention given to uncal venous drainage. CONCLUSION: There are several variations in UV termination according to the embryological development of the primitive tentorial sinus and the deep telencephalic vein. Careful attention should be paid to uncal venous drainage for the treatment of CSDAVFs.

Maxillary artery: functional and imaging anatomy for safe and effective transcatheter treatment.

The maxillary artery is a terminal branch of the external carotid artery. Although the main maxillary artery trunk and most of its branches course within the extracranial space and supply the organs and muscles of the head and neck, other surrounding soft tissues, and the oral and rhinosinusal cavities, other branches supply the dura mater and cranial nerve and can anastomose to the internal carotid artery (ICA). Various pathologic conditions of the intracranial, head, and neck regions can involve the branches of the maxillary artery. Many of these diseases can be treated with endovascular approaches; however, there is a potential risk of complications in the brain parenchyma and cranial nerves related to the meningoneuronal arterial supply and anastomoses to the ICA. Therefore, familiarity with the functional and imaging anatomy of the maxillary artery is essential. In the past, conventional angiography has been the standard imaging technique for depicting the maxillary artery anatomy and related pathologic findings. However, recent advances in computed tomographic, magnetic resonance, and rotational angiography have further elucidated the maxillary artery anatomy by means of three-dimensional representations. Understanding the functional and imaging anatomy of the maxillary artery allows safe and successful transcatheter treatment of pathologic conditions in the maxillary artery territories.

Spinal ventral epidural arteriovenous fistulas of the lumbar spine: angioarchitecture and endovascular treatment.

INTRODUCTION: Spinal ventral epidural arteriovenous fistulas (EDAVFs) are relatively rare spinal vascular lesions. We investigated the angioarchitecture of spinal ventral EDAVFs and show the results of endovascular treatment. METHODS: We reviewed six consecutive patients (four males and two females; mean age, 67.3 years) with spinal ventral EDAVFs treated at our institutions from May 2011 to October 2012. All patients presented with progressive myelopathy. The findings of angiography, including 3D/2D reformatted images, treatments, and outcomes, were investigated. A literature review focused on the angioarchitecture and treatment of spinal ventral EDAVFs is also presented. RESULTS: The EDAVFs were located in the ventral epidural space at the L1-L5 levels. All EDAVFs were supplied by the dorsal somatic branches from multiple segmental arteries. The ventral somatic branches and the radiculomeningeal arteries also supplied the AVFs in two patients. The AVFs drained via an epidural venous pouch into the perimedullary vein in four patients and into both the perimedullary vein and paravertebral veins in two patients. Four cases without paravertebral drainage were treated by transarterial embolization with diluted glue, and two cases with perimedullary and paravertebral drainages were treated by transvenous embolization alone or in combination with transarterial embolization. An angiographic cure was obtained in all patients. Clinical symptoms resolved in two patients, markedly improved in three patients, and minimally improved in one patient. CONCLUSION: In our limited experience, spinal ventral EDAVFs were primarily fed by somatic branches. EDAVFs can be successfully treated by endovascular techniques selected based on the drainage type of the AVF.

Anatomic features and retrograde transvenous obliteration of duodenal varices associated with mesocaval collateral pathway.

PURPOSE: To evaluate techniques and efficacy of retrograde transvenous obliteration for the treatment of duodenal varices associated with mesocaval collateral pathway. MATERIALS AND METHODS: Six consecutive cases of large/growing or ruptured duodenal varices treated by retrograde transvenous obliteration were retrospectively reviewed. Selective balloon-occluded retrograde transvenous obliteration (B-RTO) with 5% ethanolamine oleate (EO) was performed in all cases. When EO could not be sufficiently stagnated in the varices, additional/alternative techniques were performed, including coil embolization of afferent vein or intravariceal injection of n-butyl-2-cyanoacrylate (NBCA). Clinical findings, anatomic features of duodenal varices, obliteration techniques, complications, posttherapeutic computed tomography (CT) findings, and follow-up endoscopic findings were investigated. RESULTS: All duodenal varices were located at the second/third junction of the duodenum and were fed by single (n = 1) or multiple (n = 5) pancreaticoduodenal veins. One varix fed by a single afferent vein was successfully treated by simple selective B-RTO technique alone. The other five cases required coil embolization of afferent vein (n = 1) or intravariceal injection of NBCA (n = 4) because sclerosant was not sufficiently stagnated in the varices. CT 1 week after the procedure showed complete occlusion of the varices in all cases. A duodenal ulcer at the variceal site developed in one patient and was successfully treated by medication. Follow-up endoscopy showed disappearance of varices in all cases, and no recurrence was observed during follow-up. CONCLUSIONS: Retrograde transvenous obliteration is an effective technique for the treatment of duodenal varices. However, additional/alternative techniques are required for successful treatment because of the complex anatomic features of duodenal varices.

Partial thrombosis of gastric varices after balloon-occluded retrograde transvenous obliteration: CT findings and endoscopic correlation.

OBJECTIVE: The purpose of our study was to investigate the frequency and outcomes of partial thrombosis of gastric varices after balloon-occluded retrograde transvenous obliteration (BRTO). MATERIALS AND METHODS: We reviewed retrospectively 69 consecutive patients with gastric varices who were followed-up for > 6 months after treatment with BRTO. All patients underwent contrast-enhanced CT and gastroscopy before and after BRTO. Imaging findings of gastric varices with particular attention to afferent veins, degree of thrombosis, and variceal changes were investigated. RESULTS: On the basis of pretherapeutic CT images, gastric varices were classified into two types: simple (< 3 afferent veins) and complex (≥ 3 afferent veins). Initial follow-up CT showed complete thrombosis in 58 patients (84%) and partial thrombosis in 11 (16%). Partial thrombosis was observed more frequently in complex-type varices (25% vs 9%). No regrowth or recurrent varices were observed in completely thrombosed varices. Follow-up endoscopy showed regrowth of gastric varices at 6-24 months after BRTO in five patients; all of these were complex-type and partially thrombosed varices. All five recurrent varices were treated successfully with repeated BRTO. CONCLUSION: Partial thrombosis after BRTO can occur in complex-type gastric varices, which have a higher risk of regrowth. Additional techniques that achieve complete thrombosis are required for long-term efficacy for complex-type gastric varices.

Endovascular recanalization of acute intracranial vertebrobasilar artery occlusion using local fibrinolysis and additional balloon angioplasty.

INTRODUCTION: Vertebrobasilar artery occlusion (VBO) produces high mortality and morbidity due to low recanalization rate utilization in endovascular therapy. The use of percutaneous transluminal angioplasty (PTA) to improve recanalization rate additional to local intra-arterial fibrinolysis (LIF) was investigated in this study. Results obtained following recanalization therapy in acute intracranial VBO are reported. METHODS: Eighteen consecutive patients with acute VBO underwent LIF with or without PTA, from August 2000 to May 2006. Eight patients were treated using LIF alone, and ten required additional PTA. Rate of recanalization, neurological status before treatment, and clinical outcomes were evaluated. RESULTS: Of 18 patients, 17 achieved recanalization. One procedure-related complication of subarachnoid hemorrhage occurred. Overall survival rate was 94.4% at discharge. Seven patients achieved good outcomes [modified Rankin scale (mRS) 0-2], and the other 11 had poor outcomes (mRS 3-6). Five of six patients who scored 9-14 on the Glasgow Coma Scale (GCS) before treatment displayed good outcomes, whereas ten of 12 patients who scored 3-8 on the GCS showed poor outcomes. GCS prior to treatment showed a statistically significant correlation to outcomes (p < 0.05). Moreover, the National Institutes of Health Stroke Scale (NIHSS) before treatment correlated well with mRS (correlation coefficient 0.487). No statistical difference between the good and poor outcome groups was observed for the duration of symptoms, age, etiology, and occlusion site. CONCLUSIONS: Endovascular recanalization can reduce mortality and morbidity of acute VBO. Good GCS and NIHSS scores prior to treatment can predict the efficacy of endovascular recanalization.

Arterial supply to the pancreas; variations and cross-sectional anatomy.

The pancreas has complex arterial supplies. Therefore, special attention should be paid in pancreatic arterial intervention for patients with acute pancreatitis and pancreatic carcinomas. Knowledge of pancreatic arterial anatomy and arterial territory is important not only to perform pancreatic arterial intervention, but to read the pancreatic angiography and cross-sectional image. We reviewed 226 selective abdominal angiography and CT scans during selective arteriography (CTA) of common hepatic artery, superior mesenteric artery, splenic artery, or peripancreatic arteries including posterior superior pancreaticoduodenal artery, anterior superior pancreaticoduodenal artery, inferior pancreaticoduodenal artery, and dorsal pancreatic artery. CTA images were evaluated to clarify the cross-sectional anatomy of the pancreatic arterial territory. Variations of the peripancreatic arteries were also investigated. In this exhibit, schemes and illustrative cases demonstrate pancreatic arterial territory and variations.

Basal cerebral venous drainage from cavernous sinus dural arteriovenous fistulas.

INTRODUCTION: This study aimed to define the patterns of basal cerebral venous drainage (BCVD) from cavernous sinus dural arteriovenous fistulas (CSDAVFs). MATERIALS AND METHODS: Forty sets of selective angiographic data from 36 patients with spontaneous CSDAVFs (age range, 53-79 years) were retrospectively analyzed for their drainage patterns. Three types of BCVD were observed, i.e., superolateral type, BCVD via the deep middle cerebral vein or uncal vein; posterolateral type, BCVD via the superior petrosal sinus and petrosal vein; and posteromedial type, BCVD via the bridging vein and the anterior pontomesencephalic vein. MR images and/or 3D-DSA images were also reviewed when available. RESULTS: BCVD from CSDAVF was found in 12 patients (30%), and the other drainage routes included the superior ophthalmic vein in 25 (63%), the inferior petrosal sinus in 17 (43%), the superficial middle cerebral vein in 17 (43%), intercavernous sinus in 15 (38%), the superior petrosal sinus in seven (18%), and pterygoid plexus in two (5%), respectively. In 12 patients with BCVD, superolateral type was found in four (33%), posterolateral type in five (42%), and posteromedial type in seven (58%). Four cases of posteromedial type were associated with other types of BCVD. CONCLUSION: CSDAVFs are often associated with BCVD via three different pathways. The posteromedial type via the bridging vein is the most frequent type of BCVD.

The anterior medullary-anterior pontomesencephalic venous system and its bridging veins communicating to the dural sinuses: normal anatomy and drainage routes from dural arteriovenous fistulas.

INTRODUCTION: We evaluated the normal venous anatomy of the anterior medullary/anterior pontomesencephalic venous (AMV/APMV) system and bridging veins connected to the dural sinuses using magnetic resonance (MR) imaging and demonstrated cases of dural arteriovenous fistulas (DAVFs) with bridging venous drainage. MATERIALS AND METHODS: MR images obtained using a 3D gradient echo sequence in 70 patients without lesions affecting the deep or posterior venous channels were reviewed to evaluate the normal anatomy of the AMV/APMV system and bridging veins. MR images and digital subtraction angiography in 80 cases with intracranial or craniocervical junction DAVFs were reviewed to evaluate the bridging venous drainage from DAVFs. RESULTS: MR images clearly revealed AMV/APMV in 35 cases. Fifteen cases showed a direct connection between AMV and APMV, while 15 cases showed an indirect communication via the transverse pontine vein or the bridging vein. In the five remaining cases, the AMV and APMV end separately to the bridging vein or the transverse pontine vein. Bridging veins were identified in 34 cases, connecting to the cavernous sinus in 33, to the suboccipital cavernous sinus in 11, and the inferior petrosal sinus in five cases. In 80 DAVF cases, seven of 40 cavernous sinus DAVFs, two craniocervical junction DAVFs, and one inferior petrosal sinus DAVF drained via bridging veins to the brain stem. CONCLUSION: The AMV/APMV and bridging veins showed various anatomies and frequently showed a connection to the cavernous sinus. Knowledge of the venous anatomy is helpful for the diagnosis and intravascular treatment of DAVFs.

Small in-stent Low Density on CT Angiography after Carotid Artery Stenting.

SUMMARY: Carotid stenting (CAS) for carotid stenosis has developed rapidly over the last decade. Instent low density area supposed plaque protrusion or thrombus is sometimes observed on CT angiography after CAS. We evaluate the frequency and time course of the small in-stent low density after carotid artery stenting and discuss its nature and clinical significance. Between May 2005 to November 2007, 23 CASs were performed for 20 patients with carotid artery stenosis. All patients had no instent defect on digital subtraction angiography (DSA) immediately after the procedure. Followup CT angiography was performed at seven 7-10 days, 1-2 months, 6 months, and then every 6 months following CAS. We retrospectively reviewed the follow-up CT angiographic findings and clinical ischemic events. Small in-stent low density areas on CT angiography were observed in 6 lesions (26%). Four cases were added warfarin to antiplatlets and the other two cases had antiplatlets only. The in-stent low density areas were disappeared within four months after CAS and no ischemic event was observed in five patients. In the other patient, a small in-stent low density area had decreased at one month after CAS, but another small in-stent low density area appeared at five months. Subacute small in-stent low density areas were frequently observed on CT angiography following CAS, however, the low density area will disappear without clinical events by medication in most case.

Development of a new coaxial balloon catheter system for balloon-occluded retrograde transvenous obliteration (B-RTO).

PURPOSE: To develop a new coaxial balloon catheter system and evaluate its clinical feasibility for balloon-occluded retrograde transvenous obliteration (B-RTO). METHODS: A coaxial balloon catheter system was constructed with 9 Fr guiding balloon catheter and 5 Fr balloon catheter. A 5 Fr catheter has a high flexibility and can be coaxially inserted into the guiding catheter in advance. The catheter balloons are made of natural rubber and can be inflated to 2 cm (guiding) and 1 cm (5 Fr) maximum diameter. Between July 2003 and April 2005, 8 consecutive patients (6 men, 2 women; age range 33-72 years, mean age 55.5 years) underwent B-RTO using the balloon catheter system. Five percent ethanolamine oleate iopamidol (EOI) was used as sclerosing agent. The procedures, including maneuverability of the catheter, amount of injected sclerosing agent, necessity for coil embolization of collateral draining veins, and initial clinical results, were evaluated retrospectively. The occlusion rate was assessed by postcontrast CT within 2 weeks after B-RTO. RESULTS: The balloon catheter could be advanced into the proximal potion of the gastrorenal shunt beyond the collateral draining vein in all cases. The amount of injected EOI ranged from 3 to 34 ml. Coil embolization of the collateral draining vein was required in 2 cases. Complete obliteration of gastric varices on initial follow-up CT was obtained in 7 cases. The remaining case required re-treatment that resulted in complete obstruction of the varices after the second B-RTO. No procedure-related complications were observed. CONCLUSION: B-RTO using the new coaxial balloon catheter is feasible. Gastric varices can be treated more simply by using this catheter system.

Shapability, memory, and luminal changes in microcatheters after steam shaping: a comparison of 11 different microcatheters.

PURPOSE: The purpose of this study was to compare the characteristics of shaped microcatheters, including shapability, durability, and luminal changes. MATERIALS AND METHODS: Eleven brands of steam-shaped microcatheters and one brand of preshaped microcatheter were evaluated. There were 2 nonreinforced and 10 reinforced devices supported by coils. For evaluation of shapability, the tip angle of 6 samples of each brand were measured after steam-shaping for 20 seconds with a shaping mandrel bent at a 90 degrees or 150 degrees angle. The ability to maintain the shaped angle after guidewire insertion stress (durability) was compared by calculation of the change in the tip angle by using 3 samples of each brand. Luminal change after steam shaping was evaluated by calculation of narrowing rate of the smallest diameter and observation of the surface morphology of the mold of each catheter lumen by using a silicone polymer by means of a fluorescent projection method. RESULTS: The nonreinforced microcatheters and the fiber-braided microcatheter showed higher shapability than the others. The degree of distal microcatheter straightening with the microguidewire insertion was less pronounced in the preshaped microcatheter and the fiber-braided microcatheter. Spontaneous recovery to the initial tip angle 5 minutes after the guidewire procedure was observed in 10 brands to various degrees (87%-98%). Irregular luminal surface morphology at the angled portion was found in 6 reinforced brands. One nonreinforced catheter and the fiber-braided catheter showed high narrowing rates >6%. CONCLUSION: There are differences in shapabilty, durability, and luminal changes of steam shaping in 12 brands of microcatheters. These characteristics could be important factors in catheter choice for endovascular procedures.

Treatment of intracranial dural arteriovenous fistulas: current strategies based on location and hemodynamics, and alternative techniques of transcatheter embolization.

Intracranial dural arteriovenous fistulas (AVFs) can occur anywhere within the dura mater. Patients may be clinically asymptomatic or may experience symptoms ranging from mild symptoms to fatal hemorrhage, depending on the location (eg, cavernous sinus, transverse-sigmoid sinus, tentorium, superior sagittal sinus, anterior fossa) and venous drainage pattern of the AVF. In the past, dural AVFs have been treated with a variety of approaches, including surgical resection, venous clipping, transcatheter embolization, radiation therapy, or a combination of these treatments. Recent developments in catheter intervention now allow most patients to be cured with transcatheter embolization, although stereotactic radiation therapy is demonstrating good results in an increasing number of cases and surgery is still the preferred option in some cases. Familiarity with drainage patterns, the risk of aggressive symptoms, recent technical advances, and current treatment strategies is essential for the treatment of intracranial dural AVFs.

Clinical use of a new mechanical detachable coil system for percutaneous intravenous embolization of cavernous sinus dural arteriovenous fistulas.

PURPOSE: The purpose of this study was to evaluate the usefulness of a new mechanical detachable coil system (Detach-18/-11) for percutaneous transvenous embolization (TVE) of dural arteriovenous fistulas (AVFs) involving the cavernous sinus. MATERIALS AND METHODS: Five patients with dural AVF involving the cavernous sinus were treated by TVE with the use of the Detach-18/-11 system alone. All procedures were analyzed with regard to the processes of introduction, delivery, and/or retrieval of the Detach-18/-11 system, and angiographical and clinical outcome. RESULTS: A total of 70 detachable coils (37 spiral-type coils and 33 J-type coils) were used. Two coils were easily retrieved after introduction. The remaining 68 coils were easily delivered within 30 seconds. Neither premature detachment nor coil migration was observed. Of the five dural AVFs, three were completely occluded and two were nearly completely occluded immediately after embolization. Follow-up angiography showed complete occlusion in all cases. Clinical symptoms had disappeared within one month, and no recurrent symptoms were observed during follow-up (from 5 to 36 months). CONCLUSION: Our results support the safety and reliability of the Detach-18/-11 system for TVE of dural AVF. The availability of various types of this coil system allows sufficient packing of the involved sinus.