Kojiro Ishikawa

A Stent-Retrieving into an Aspiration Catheter with Proximal Balloon (ASAP) Technique: A Technique of Mechanical Thrombectomy

OBJECTIVE The best technique for the first attempt at mechanical thrombectomy for acute ischemic stroke is a still matter of debate. In this study, we evaluate the efficacy of a stent-retrieving into an aspiration catheter with proximal balloon (ASAP) technique that uses a series of thrombus extraction by withdrawing the stent retriever into the aspiration catheter and continuous aspiration from the aspiration catheter at the first attempt. METHODS We performed a retrospective analysis of 42 consecutive patients with acute ischemic stroke caused by occlusions in the anterior circulation who were treated with the ASAP technique at our institution. Preoperative patient characteristic, including age, thrombus location, Alberta Stroke Program Early CT Score, National Institutions of Health Stroke Scale, and time from onset to puncture; postoperative Thrombolysis in Cerebral Infarction score; modified Rankin Scale score after 3 months; time from puncture to recanalization; the number of passes to achieve recanalization; and procedural complications, including intracranial hemorrhage, embolization to new territory, and distal embolization, were assessed. RESULTS A Thrombolysis in Cerebral Infarction score of 2B or 3 was achieved in 40/42 patients (95.2%). Average time from puncture to the final recanalization was 21.5 minutes. Recanalization was achieved in a single attempt in 31 patients (77.5%). Embolization to new territory was observed in only 2 patients (4.8%); no patient developed distal embolization or intracranial hemorrhage including asymptomatic subarachnoid hemorrhage. Thirty-two patients (76.2%) achieved modified Rankin Scale scores of 0-2 at 3 months postoperatively. CONCLUSIONS Our ASAP technique showed fast recanalization, minimal complications, and good clinical outcomes in this case series.

Suitability of a 7-F ExoSeal Vascular Closure Device for Femoral Artery Punctures Made by 8-F or 9-F Introducer Sheaths

Purpose: To establish the safety and efficacy of the 7-F ExoSeal device for the closure of femoral puncture sites made by 8-F or 9-F introducer sheaths. Methods: Between January 2013 and December 2016, 332 patients (mean age 68.4±12.1 years; 195 men) underwent neurointerventional procedures via percutaneous puncture of the common femoral artery and an 8-F (n=272, 81.9%) or 9-F (n=60, 18.1%) introducer. The access sites were sealed with a 7-F ExoSeal in all cases. Procedure success and closure-related complication rates were evaluated, and risk factors for complications were analyzed by comparing patient characteristics between those who did and did not experience complications. Results: Procedure success rates were 99.3% in the 8-F group and 100% in the 9-F group. The overall complication rate was 6.3% (n=17; all in the 8-F group), of which 13 (4.8%) were minor sequelae, including access-site hematoma (n=8), oozing (n=3), pseudoaneurysm (n=1), and retroperitoneal bleeding (n=1). Among the 4 (1.5%) major complications were 3 instances of bleeding requiring a blood transfusion and 1 surgical vascular repair. No complications were observed in the 9-F group. Patients who experienced complications had significantly longer activated clotting times (262±46 vs 218±55 seconds; p<0.001) compared with patients without complications. Conclusion: A 7-F ExoSeal vascular closure device is safe and effective for the closure of femoral puncture sites made by 8-F or 9-F introducer sheaths.

Efficacy of carotid thrombus penetration with a balloon guiding catheter to fast recanalization of acute extra- and intra-cranial carotid artery tandem occlusion - a preliminary report

Abstract Acute ischemic stroke with ipsilateral Internal carotid artery (ICA) stenosis presents a great management dilemma. We present our preliminary report of retrograde retrieval of clot from middle cerebral artery (MCA) followed by delayed carotid artery stenting (CAS) with dual anti platelet therapy (DAPT).

Posterior Meningeal Artery Origin Patterns among 300 Cases and Their Clinical Importance

BACKGROUND AND PURPOSE The posterior meningeal artery (PMA) is known as a dura mater-nourishing vessel. We encountered a patient with Wallenberg syndrome during transarterial embolization of the PMA associated with the dural arteriovenous fistula (DAVF). METHODS After development of Wallenberg syndrome in the patient, we assessed origins of the PMA patterns in 300 cases and divided them into 3 types. CASE PRESENTATION A 63-year-old man was incidentally diagnosed as having transverse-sigmoid sinus DAVF with a cortical venous reflux. During the transarterial embolization, the patient complained of vertigo and numbness of the right extremities. Postoperatively, the patient exhibited Wallenberg syndrome. Diffusion-weighted magnetic resonance imaging showed a high-intensity area on the lateral side of the right medulla. CONCLUSIONS While performing arterial embolization of the PMA that directly originates from the intracranial vertebral artery, the possibility of deficient brainstem nourishment must be considered.

Long-Lasting Symptomatic Cerebral Hyperperfusion Syndrome following Superficial Temporal Artery-Middle Cerebral Artery Bypass in a Patient with Stenosis of Middle Cerebral Artery

Cerebral hyperperfusion syndrome (CHPS) is a complication that can occur after cerebral revascularization surgeries such as superficial temporal artery- (STA-) middle cerebral artery (MCA) anastomosis, and it can lead to neurological deteriorations. CHPS is usually temporary and disappears within two weeks. The authors present a case in which speech disturbance due to CHPS lasted unexpectedly long and three months was taken for full recovery. A 40-year-old woman, with a history of medication of quetiapine, dopamine 2 receptor antagonist as an antipsychotics for depression, underwent STA-MCA anastomosis for symptomatic left MCA stenosis. On the second day after surgery, the patient exhibited mild speech disturbance which deteriorated into complete motor aphasia and persisted for one month. SPECT showed the increase of cerebral blood flow (CBF) in left cerebrum, verifying the diagnosis of CHPS. Although CBF increase disappeared one month after surgery, speech disturbance continued for additionally two months with a slow improvement. This case represents a rare clinical course of CHPS. The presumable mechanisms of the prolongation of CHPS are discussed, and the medication of quetiapine might be one possible cause by its effect on cerebral vessels as dopamine 2 receptor antagonist, posing the caution against antipsychotics in cerebrovascular surgeries.

Parent and Child Balloon Technique for Navigating Guide Catheters During Neurointerventions

BACKGROUND The stabilization of a guide catheter is an important factor for performing successful neurointerventional procedures. We present our technique for navigating guide catheters using parent and child balloons. METHODS In 9 patients with severe atherosclerosis or anatomic variations such as a bovine arch, 8-9-F balloon-mounted guide catheters were navigated using balloon-attached guidewires. Both balloons were used complementarily for flow navigation and vessel fixation at the appropriate positions and times. RESULTS In all cases, the balloon guide catheter could be inserted up to the required positions, and the procedures were completed without any complications. CONCLUSIONS The parent and child balloon technique is useful for inserting guide catheters in hostile vascular anatomies.

Feasibility and Safety of Distal and Proximal Combined Endovascular Approach with a Balloon-Guiding Catheter for Subclavian Artery Total Occlusion

BACKGROUND Symptomatic subclavian artery total occlusion is widely treated with an endovascular procedure that often results in distal vertebral artery embolism. Therefore, protection devices are important. Establishing a filter or balloon device in the vertebral artery can protect against this distal embolism. However, the use of embolic protection devices is not easy, and it makes the procedure more complicated. Here, we report a case of symptomatic subclavian artery total occlusion that was treated successfully with a balloon-guiding catheter and the pull-through technique. CASE DESCRIPTION A 67-year-old man developed intermittent motor weakness in his left arm. Aortic angiography demonstrated a complete occlusion of the left proximal subclavian artery and a retrograde flow through the left vertebral artery to the distal brachial artery. In this case, we used a balloon-guiding catheter and the pull-through technique to prevent distal embolism. The balloon-guiding system was useful not only for embolic protection but also for scaffold during excavation and for the centering effect against invisible vessels. The pull-through technique enabled our devices to deliver easily and smoothly. The patient was treated successfully without complications. CONCLUSIONS The distal and proximal combined endovascular treatment with a transbrachial balloon-guiding catheter is a beneficial treatment option for patients with subclavian artery total occlusion.

Experimental evaluation and training of stent clot retrieval : the confront clot scrambling method

ABSTRACT The introduction of stent retrievers has changed the methods used for acute intracranial thrombectomy, but the training approach has not been discussed enough. We, therefore, aimed to establish a simple skill up method which can be used to train anytime and anywhere with low costs. Also, we introduce our experimental confront clot scrambling method (CCSM) which makes a profitable visualization in how the stent retriever works. The CCSM involved a sham clot set in the middle of a polyvinyl chloride tube, after which two stent retrievers were navigated from each side before being simultaneously withdrawn with the same force. The stent that removes the sham clot is determined to have stronger clot retrieval ability. Several adjunctive techniques were also compared. The push and fluff adjunctive technique was the most effective among all the stents. Generally, the former deployed stent was stronger than later one. Therefore, the later deployed stent with the push and fluff technique lets us know whether the physician’s maneuver worked well or not. CCSM could directly evaluate the ability of adjunctive techniques with each stent retriever and demonstrate the physicians’ skills. Because the actual endovascular clot retrieval requires extreme fine maneuvers against invisible vessels, repeat training is very important especially in beginners.

A case of anterior communicating artery aneurysm successfully treated after a stent migration during stent assisted endovascular coil embolization

ABSTRACT Stent migration is a complication associated with endovascular coil embolization of intracranial aneurysms. We report a case of anterior communicating artery (ACoA) aneurysm that was successfully treated after stent migration during endovascular coil embolization without retrieval of the stent. A 47-year-old man presented with sudden onset severe headache. Patient was noted to have subarachnoid hemorrhage from a ruptured ACoA aneurysm. Emergency endovascular coil embolization was performed. The second coil embolization was scheduled for the neck-remnant portion with a stent after 16 days from the initial operation. At first, a stent was deployed from the right perpendicular division of anterior cerebral artery (A2) to the left horizontal division of anterior cerebral artery (A1) entirely across the aneurysmal neck. Although the stent position looked fine, the stent migrated inferiorly to the proximal A1 portion when its delivery wire was withdrawn. Fortunately, the stent could be pushed into the distal A1 portion, when we trying to re-access the aneurysm thorough the stent with a pig-tail shaped microguidewire. Additional coil embolization was achieved using the assistance of distal tip of the stent as a scaffold of the coil. The patient was discharged without any complication on the postoperative day 6. Although there are various choices of rescue treatment after stent migration, this is the first reported case of stent repositioning with a microguidewire. Our technique may represent an effective option in case of stent migration.

Hemispheric divided coiling technique for coil embolization of middle- and large-sized intracranial aneurysms

ABSTRACT Despite major developments in treating intracranial aneurysms by endovascular coil embolization, complete occlusion of the entire aneurysmal neck remains a problem. We present a novel endovascular strategy for middle- and large sized aneurysms called the “hemispheric divided coiling technique” and compare the short-term follow-up results of this technique with those of conventional coil embolization. Ten patients (mean age, 69.7 ± 9.7 years) with middle- or large-sized ruptured or unruptured intracranial aneurysms (mean maximum aneurysmal diameter, 12.09 ± 3.6 mm) were treated by the hemispheric divided coiling technique, in combination with various adjunctive techniques. We compared the initial occlusion grade, volume embolization ratio, and recurrence rate in this group of patients (hemispheric group) with the results from 20 previous cases (conventional group: mean age, 62.8 ± 9.8 years; mean maximum aneurysmal diameter, 11.43 ± 3.5 mm). The mean volume embolization ratio of the hemispheric group was significantly higher than that of the conventional group (42.3% vs. 31.1%). The hemispheric divided coiling technique achieved a high volume embolization ratio for middle- and large sized intracranial aneurysms, with a low recurrence rate.