Trans-umbilical access in the neonate with sheath preservation for intervention.

High-flow vascular malformations in neonates may require emergent embolization to prevent or treat congestive heart failure when intervention is indicated.1 While transfemoral access is the traditional approach, this route may be complicated by the sheath size (typically 4F in our experience, as a smaller sheath system may prove suboptimal) needed for embolization. This is especially true when (1) multiple acute interventions are anticipated during the neonatal period and/or (2) when it is preferred to spare femoral access for future treatments in infancy or childhood.1-3 The safety and feasibility of using transumbilical (TU) access via the umbilical artery and maintaining an indwelling sheath post-procedurally has been previously described and indeed does spare the femoral arteries for later treatments; however, this technique has not yet been sufficiently demonstrated or reported to the extent that it could be easily reproduced.1-10 In this technical video, we detail the required materials and demonstrate a step-by-step guide to obtaining TU access in the context of neonatal vascular malformation embolization. Our practice has utilized this technique for decades and we hope that by sharing our methods with the neurointerventional community we may make this rarely performed procedure a feasible option for proceduralists (see video 1) .neurintsurg;jnis-2024-021561v1/V1F1V1Video 1Technical instructional video for trans-umbilical access in the neonate with sheath preservation for intervention.

Evolution of transvenous embolization in vein of Galen malformation: case series and review of the literature.

BACKGROUND: Treatment of vein of Galen malformations (VOGMs) has improved greatly since the inception of endovascular treatment. Transvenous embolization (TVE) is an attractive option to achieve complete obliteration. OBJECTIVE: To review the literature on TVE of VOGM and then analyze our practice's unique experience and evolving treatment strategies over 30 years. METHODS: A retrospective review of our clinical database for patients with the diagnosis of VOGM treated between January 2004 and August 2021 was performed. A literature review of 49 relevant articles was also carried out. RESULTS: TVE in VOGM has evolved with initial introduction as a transtorcular (TT) approach, which then lost favor to transarterial embolization (TAE). TAE has been considered the more favorable approach in most high-volume centers. In more recent times, the transvenous embolization (TVE) approach has been revisited as a last treatment to achieve a cure after a series of TAE treatments. We presently favor beginning treatment with staged TAE to reduce flow to the lesion and, importantly, shrink the draining vein. This then allows for the performance of TVE with the Chapot pressure cooker technique (CPCT) with coils and liquid embolic embolization. CONCLUSIONS: TT TVE itself carries a high degree of risk and is most highly associated with long-term morbidities and mortality. Traditional transfemoral/transjugular TVE approaches are safe and effective in simple fistulas with a small venous pouch; however, we believe that the CPCT is the safest technique as a last-stage treatment for its security in avoiding reflux and obtaining occlusion of the small perforators.

Low-memory shape coils for intracranial aneurysm coiling: Initial and single-center experience with the i-ED coil.

Background: Endovascular aneurysmal coiling is a preventative alternative to clipping to avoid aneurysmal rupture. In the literature and our own experience, some common coiling challenges which arise include: (1) microcatheter kickback, (2) detachment zone rigidity, (3) intrasaccular compartmentalization of coils on deployment, and (4) attainability of high-density and effective packing with as few coils as possible. Methods: We retrospectively reviewed a consecutive case series of 15 intracranial aneurysm patients who received Kaneka i-ED Coils since their initial use in our practice (December 2020) till May 2022. Results: Of the 14 saccular aneurysm patients treated with i-ED coils, 2/14 (14.3%) achieved a Raymond-Roy (RR) score of 3A (internal remnant), 4/14 (28.6%) achieved RR 2 (slight neck remnant) and 8/14 (57.1%) achieved RR 1. One MoyaMoya patient (5.9%) with a fusiform aneurysm also achieved a complete occlusion by parent artery takedown in this series. Aneurysm volumes ranged from 8.15 mm 3 to 315.5 mm 3 with an average packing density of 36.23% and a standard deviation 8.87%. At 30 days, most of our cohort scored a 0 on the modified Rankin scale (mRS) (11/15), with two patients scoring at an mRS score of 1, one at an mRS score of 4, and one at an mRS score of 6. Low-memory shape, coil cases achieved a significantly higher packing density (P < 0.01) and PD/Coils-used ratio (P < 0.05) than other cases in our practice. Conclusion: Our initial experience with i-ED coils has shown that they are a feasible strategy in a number of differently sized and shaped aneurysms. While fewer coils overall were not a statistically significant finding in this study, the future studies with larger cohorts are necessary and in progress.

Percutaneous sclerotherapy of microcystic lymphatic malformations: the use of an innovative gravity-dependent technique.

BACKGROUND: In the last few decades there has been development of innovative therapies for the treatment of craniofacial lymphatic malformations. Percutaneous sclerotherapy has demonstrated efficacy in the management of macrocystic lymphatic lesions, but it is less suitable for microcystic lesions given their size. The gravity-dependent technique is a novel augmentation of standard percutaneous sclerotherapy: the technique enables a sclerosing agent to permeate the small microchannels seen in microcystic lesions that would otherwise be difficult to treat. METHODS: Between 2005 and 2021, 124 patients with microcystic or mixed lymphatic malformations were treated using a novel gravity-dependent sclerotherapy technique. Bleomycin at a maximum dose of 15 IU per session was used as the main sclerosing agent. Fluoroscopy and ultrasound were used to ensure proper positioning of the catheter prior to injecting the sclerosing agent. The response to treatment was assessed clinically and with cross-sectional imaging. RESULTS: Nearly all cases showed significant improvement after the gravity-dependent technique. There have been no permanent complications from sclerotherapy treatment. There was a mild transient adverse effect from bleomycin in one case of erythema and tenderness that lasted several weeks then ameliorated. CONCLUSIONS: The gravity-dependent sclerotherapy technique is a suitable treatment option for microcystic lymphatic malformations.