Transcervical access via direct neck exposure for neurointerventional procedures in the hybrid angiosuite

Endovascular recanalization therapy for patients with acute ischemic stroke with hidden aortic dissection: A case series

Aortic dissection is one of the causes of acute ischemic stroke. Endovascular recanalization therapy (EVT) has emerged as an essential treatment for acute ischemic stroke due to large artery occlusion. However, it is rarely performed in the situation of hidden aortic dissection (AD). Two patients presented to the emergency room with focal neurologic deficits. The first patient was diagnosed with right internal carotid artery (ICA) occlusion. Angiography revealed that the ICA was occluded by the dissection flap. After a stent deployment in the proximal ICA, the antegrade flow was restored. The patient was diagnosed with AD on chest computed tomography (CT) after EVT. For the second patient, intraarterial thrombectomy was performed to treat left middle cerebral artery occlusion. AD was first detected on echocardiography, which was performed after EVT. Herein, we report successful endovascular recanalization therapy performed in two patients with acute ischemic stroke in the situation of undiagnosed aortic dissection. We also reviewed previous case reports and relevant literature.

Surgical exposure of the vertebral artery for endovascular access in a hybrid operating room

PURPOSE

Endovascular procedures are a desirable treatment option for neurovascular lesions in posterior circulation. However, endovascular access occasionally fails due to tortuosity of the proximal vertebral artery (VA), aortic arch, and/or VA ostium stenosis. We aimed to describe the creation of endovascular access via surgical exposure of the VA in a hybrid operating room to overcome anatomical difficulties hampering distal access to the VA through the transfemoral or transradial approach.

METHODS

We present six patients with seven posterior circulation lesions in whom distal access via the conventional approach to the VA was impossible. Surgical exposure of the VA was performed to provide endovascular access to these patients. Radiographic characteristics, operative techniques, and outcomes were reviewed.

RESULTS

Surgical exposure of the VA was performed in six patients with cerebral aneurysm (n = 4) and symptomatic stenosis of the VA ostium (n = 3). There were four female and two male patients, aged 73-82 years. Surgical exposure was usually performed beyond the tortuous segments of the VA. After endovascular access was provided, coil embolization was performed for cerebral aneurysms and/or balloon angioplasty and stenting was performed to treat the VA ostium stenosis. All puncture sites were closed by direct suture using a 7-0 Prolene suture. All procedures were completed without adverse events.

CONCLUSION

Endovascular access via surgical exposure of the VA is a feasible and safe alternative for patients in whom the femoral or radial route does not allow the navigation and stabilization of the guiding catheter into the proximal segment of the VA.

Direct Carotid Artery Exposure for Acute Cerebral Infarction in Hybrid Angiography Suite: Indications and Limitations

Objectives

For the endovascular intervention of acute ischemic stroke, a transcervical route is an alternative approach in patients with challenging anatomical variations. Percutaneous puncture is a common way, but it can cause many fatal complications. Direct carotid artery exposure is an alternative for reducing complications. We demonstrate a technique of direct carotid exposure in patients for whom transfemoral or transbrachial approaches were impossible. We present patient outcomes and discuss the indications and limitations of this procedure.

Methods

We retrospectively reviewed the cases of patients undergoing direct carotid exposure for acute ischemic stroke in a hybrid angiography suite and presented the details of the technique.

Results

Among 548 consecutive patients with acute large vessel strokes who were treated by emergency endovascular thrombectomy or stenting between January 2015 and September 2020 in our center, only 8 (1.46%) required a transcervical approach. Of them, 7 underwent direct carotid exposure with successful recanalization and good clinical outcomes.

Conclusions

Direct carotid exposure for endovascular stroke treatment is effective and advantageous in patients with challenging anatomical variations. Performing this procedure in carefully selected patients in the hybrid angiography suite can be beneficial in terms of open surgeries, saving time, and decreasing the risk of postoperative complications.

Intracranial Carotid Artery Aneurysm Treatment: First Reported Case of DERIVO®Flow-Diverter Placement by Direct Carotid Artery Puncture

Brain health may be threatened by aneurysm ruptures, and early recognition of these vascular malformations allows for neuroradiological intervention. Neurointerventional procedures are usually performed with femoral artery access. In patients with severe anatomical complexity of the supra-aortic vessels, however, treatment by this approach could be hindered or impossible. Flow-diverter stent deployment is an effective and safe treatment for large, wide necked intracranial aneurysms, but it requires a complete and firm stability of the coaxial system to achieve a correct and precise deployment of the device. We present the first reported Italian case of a patient with an intracranial aneurysm which was treated with Flow-diverter stent (DERIVO^®; AcandisGmbH & Co. KG; Pforzheim; Germany) by direct common carotid artery puncture due to severe tortuosity of supra-aortic trunks.

Safety and completeness of using indocyanine green videoangiography combined with digital subtraction angiography for aneurysm surgery in a hybrid operating theater

This study aimed to evaluate the safety and completeness of using intraoperative indocyanine green videoangiography (ICGV) combined with intraoperative angiography (IOA) for aneurysm clipping in a hybrid operating room (hOR). All patients who underwent microsurgical clipping in the hOR were identified from prospectively maintained neurosurgical databases. Medical charts and operative videos with ICGV and IOA were reviewed to determine the adequacy of clipping, and clinical and angiographic outcomes were retrospectively analyzed. Fifty-four cerebral aneurysms (ruptured, 31; unruptured, 23) in 50 patients (mean age, 59.4 ± 10.9 y; M:F, 22:28) were evaluated with ICGV and IOA during clipping. Additional IOA led to a clip adjustment during surgery in 9/54 (16.7%) aneurysms for which ICGV had been initially performed. Post-clip perforator compromise occurred in two (3.7%) cases, with a patient with an unruptured aneurysm experiencing permanent injury (grade 3 hemiparesis) and patient with a ruptured aneurysm experiencing transient deficit. Post-clip parent vessel stenosis occurred in one (1.9%) case; however, an ischemic event did not occur because the flow patency was identified by IOA. No other patients with unruptured aneurysms developed new neurologic deficits at discharge. Favorable outcomes (Glasgow Outcome Score [GOS], 4 or 5) were observed in 26/31 patients with ruptured aneurysms. Five patients had unfavorable outcomes (GOS, 2 or 3) from the initial insult. Post-treatment angiography within 1 week showed complete occlusion in 52 (96.3%) aneurysms and minor remnants in two (3.7%) aneurysms. Using combined ICGV and IOA in a hOR may improve the safety and completeness of microsurgical aneurysm clipping.

Direct Neck Exposure for Rescue Endovascular Mechanical Thrombectomy in a Patient with Acute Common Carotid Occlusion Concurrent with Type A Aortic Dissection

BACKGROUND

Mechanical thrombectomy is an effective management for acute large vessel occlusion. However, when difficult anatomy is encountered in which the reperfusion catheter cannot be positioned well, the outcomes can be less than optimal. Herein, we presented a patient with right common carotid artery and internal carotid artery occlusion after repair of an acute type A aortic dissection. Successful mechanical thrombectomy and stenting through direct neck exposure and puncture was performed.

CASE DESCRIPTION

A 45-year-old male had a type A aortic dissection that presented with sudden onset neck pain and cold sweating. Aortic valve resuspension, proximal anastomosis of the ascending aortic graft, partial aortic arch graft replacement, and innominate artery reimplantation was performed. After the aortic surgery, left limb weakness was noted in the intensive care unit. Computed tomography angiography of the brain showed right common carotid artery (CCA) occlusion up to the internal carotid artery (ICA). The right CCA was exposed and directly punctured. A thrombus was successfully removed, and a total of 5 stents were deployed to treat the ICA and CCA dissection. Angiography showed a final TICI 3 result, and the patient had excellent clinically recovery.

CONCLUSIONS

Acute mechanical thrombectomy through open direct neck puncture due to an acute type A aortic dissection and concurrent CCA dissection and occlusion is an effective and optimal method.