Junpei Koge

Iatrogenic Ascending Pharyngeal Artery Injury by Predilation Balloon Inflation During Carotid Artery Stenting with Flow Reversal

BACKGROUNDnThe ascending pharyngeal artery (APA) may rarely arise from the common carotid artery bifurcation. We report an injury to the APA as an unusual complication of predilation balloon inflation during carotid artery stenting (CAS) with flow reversal.nnnCASE DESCRIPTIONnA 73-year-old man presented with symptomatic severe left cervical internal carotid artery stenosis. The left APA arose from the common carotid artery bifurcation. We performed CAS with flow reversal to decrease the risk of distal embolization. When we attempted to catheterize the internal carotid artery under roadmap guidance for predilation, we did not notice that the balloon catheters had advanced into the APA owing to the absence of an anterograde angiogram, and the APA was injured when the balloon catheters were inflated.nnnCONCLUSIONSnOur case emphasizes the importance of performing a detailed anatomic assessment before CAS and ensuring adequate angiographic visualization during the procedure under flow reversal when the origin of the APA is in the vicinity of the origin of the internal carotid artery.

Improving treatment times for patients with in-hospital stroke using a standardized protocol

BACKGROUNDnPrevious reports have shown significant delays in treatment of in-hospital stroke (IHS). We developed and implemented our IHS alert protocol in April 2014. We aimed to determine the influence of implementation of our IHS alert protocol.nnnMETHODSnOur implementation processes comprise the following four main steps: IHS protocol development, workshops for hospital staff to learn about the protocol, preparation of standardized IHS treatment kits, and obtaining feedback in a monthly hospital staff conference. We retrospectively compared protocol metrics and clinical outcomes of patients with IHS treated with intravenous thrombolysis and/or endovascular therapy between before (January 2008-March 2014) and after implementation (April 2014-December 2016).nnnRESULTSnFifty-five patients were included (pre, 25; post, 30). After the implementation, significant reductions occurred in the median time from stroke recognition to evaluation by a neurologist (30 vs. 13.5min, p<0.01) and to first neuroimaging (50 vs. 26.5min, p<0.01) and in the median time from first neuroimaging to intravenous thrombolysis (45 vs. 16min, p=0.02). The median time from first neuroimaging to endovascular therapy had a tendency to decrease (75 vs. 53min, p=0.08). There were no differences in the favorable outcomes (modified Rankin scale score of 0-2) at discharge or the incidence of symptomatic intracranial hemorrhage between the two periods.nnnCONCLUSIONnOur IHS alert protocol implementation saved time in treating patients with IHS without compromising safety.

Carotid artery stenting with proximal embolic protection via the transbrachial approach: sheathless navigation of a 9-F balloon-guiding catheter

PurposeTransbrachial carotid artery stenting (TB-CAS) is performed as an alternative procedure for patients with hostile vascular anatomy of the aortic arch and aortic or peripheral artery disease. Proximal protection during TB-CAS is not generally feasible because a small size of the brachial artery may preclude using a large-diameter sheath introducer. We, herein present a novel method that enables proximal protection during TB-CAS by sheathless navigation of a 9-F balloon-guiding catheter equivalent to a 7-F sheath.MethodsWe analyzed eight consecutive patients who underwent TB-CAS with proximal protection using the sheathless method from April 2016 to June 2017. Relevant demographic, radiographic, and procedural features were retrospectively reviewed.ResultsWe performed TB-CAS using our method for five patients with a bovine or type 3 aortic arch, for one patient with combined peripheral artery disease, and for two patients with a type 1 or 2 aortic arch. We successfully navigated the balloon-guiding catheter via the brachial artery and performed CAS under proximal flow control in all patients. However, we experienced kinking and exchange of the balloon-guiding catheter in one patient and a periprocedural thromboembolic event occurred. A pseudoaneurysm at the access site developed in one patient.ConclusionTB-CAS with proximal embolic protection using the sheathless method is feasible and may provide an alternative approach in carefully selected patients who have difficult anatomy in the transfemoral approach and plaques with a high risk of distal embolization.

Overshunting-associated myelopathy: Flattened spinal cord compressed by epidural venous plexus

A 50-year-old woman presented with a 1-month history of progressive spastic quadriparesis. She had undergone nonprogrammable ventriculoperitoneal (VP) shunt placement after intraventricular hemorrhage due to a ruptured arteriovenous malformation 16 years previously. Neurologically, she had neck extensor weakness (Medical Research Council [MRC] grade 4), symmetrical weakness of her upper extremities (right/left MRC grades 4/4), and weakness of her right proximal lower extremity (MRC grade 4). She also had spasticity and hyperreflexia in all 4 extremities with extensor plantar reflexes. Light touch and vibratory sensation was impaired in the right distal lower extremity. Neck MRI demonstrated that the cervical spinal cord was compressed from both sides by an engorged epidural venous plexus (figure 1). Brain MRI revealed diffuse pachymeningeal enhancement and slit ventricles. Overshunting-associated myelopathy (OSAM) was diagnosed. Her symptoms resolved completely 3 months after VP shunt revision (figure 2).

Successful carotid artery stenting of a dissected, highly tortuous internal carotid artery after straightening with a peripheral microguidewire

Endovascular reconstruction for carotid artery dissection (CAD) involving a highly tortuous segment of the cervical internal carotid artery (ICA) is challenging because the tortuous ICA may preclude navigation of large-profile carotid stents. Successful recanalization using low-profile neurostents has been reported in small case series only. We herein describe two patients with CAD of a tortuous segment who were successfully treated with large-profile carotid stents after straightening the ICA with a stiff peripheral microguidewire. In Case 1, a 33-year-old man presented with steno-occlusive left CAD involving coiling of the cervical ICA and left M2 occlusion. We could not navigate a carotid stent through the tortuous segment of the ICA using a standard neuro-guidewire. A carotid stent was successfully deployed after straightening the tortuous ICA with a peripheral guidewire, and subsequent thrombectomy using a large-bore aspiration catheter for the occluded M2 branch resulted in recanalization. In Case 2, a 64-year-old man presented with right steno-occlusive CAD involving kinking of the cervical ICA. We successfully deployed two carotid stents after straightening the tortuous ICA with a peripheral guidewire. Stenting after straightening with a peripheral microguidewire is feasible and may provide a therapeutic option for CAD in patients with a highly tortuous ICA.