Initial experience of a novel sheath guide for transbrachial coil embolization of cerebral aneurysms in the anterior cerebral circulation

Direct carotid exposure approach in the treatment of anterior circulation unruptured intracranial aneurysms for elderly patients

BACKGROUND AND PURPOSE

The direct carotid exposure approach (DCEA) is a technical option for elderly patients with severe vessel tortuosity due to arteriosclerosis. We evaluated complications related to antiplatelet/anticoagulant management and compared the DCEA to standard transfemoral/transbrachial approaches (TFBA) in the treatment of unruptured intracranial aneurysms for elderly patients.

METHODS

From August 2017 to August 2020, 52 patients (53 procedures) aged over 75 years with unruptured aneurysms in the anterior circulation were treated at our institution. All patients received dual antiplatelet drugs before the procedure. Eleven patients (21.2%) (12 procedures) were treated with the DCEA. The rest were treated with TFBA. The main indication of the DCEA was an unfavorable aortic arch or vessel tortuosity. Complications and the duration of the procedure were compared between the two groups.

RESULTS

There were no significant differences between the two groups in age, aneurysm location, preoperative antiplatelet use, heparin use, or maximum activated clotting time (ACT) values. All endovascular treatments were successfully performed by DCEA. Among all parameters, the DCEA group had only bigger average aneurysm diameter (14 mm) and higher number of pipeline embolic device (PED) placement (58%). Time to the guiding-catheter placement was not significantly different between the groups (DCEA vs TFBA = 31.0 min vs 24.7 min, p = 0.178).　No significant complications of DCEA, such as subcutaneous hematomas, were observed.　.

CONCLUSION

Even with the use of antiplatelet and anticoagulation therapy, the DCEA can be performed safely for unruptured aneurysms in elderly patients.

Factors Associated with Procedural Thromboembolisms after Mechanical Thrombectomy for Acute Ischemic Stroke

Background and objective: Procedural thromboembolisms after mechanical thrombectomy (MT) for acute ischemic stroke has rarely been studied. We retrospectively evaluated factors associated with procedural thromboembolisms after MT using diffusion-weight imaging (DWI) within 2 days of MT. Materials and Methods: From January 2018 to March 2020, 78 patients with acute ischemic stroke who underwent MT were evaluated using DWI. Procedural thromboembolisms were defined as new cerebral infarctions in other territories from the occluded artery on DWI after MT. Results: Procedural thromboembolisms were observed on DWI in 16 patients (20.5%). Procedural thromboembolisms were associated with old age (73.8 ± 8.18 vs. 66.8 ± 11.2 years, p = 0.021), intravenous (IV) thrombolysis (12 out of 16 (75.0%) vs. 25 out of 62 (40.3%), p = 0.023), heparinization (4 out of 16 (25.0%) vs. 37 out of 62 (59.7%), p = 0.023), and longer procedural time (90.9 ± 35.6 vs. 64.4 ± 33.0 min, p = 0.006). Multivariable logistic regression analysis revealed that procedural thromboembolisms were independently associated with procedural time (adjusted odds ratio (OR); 1.020, 95% confidence interval (CI); 1.002–1.039, p = 0.030) and IV thrombolysis (adjusted OR; 4.697, 95% CI; 1.223–18.042, p = 0.024). The cutoff value of procedural time for predicting procedural thromboembolisms was ≥71 min (area under the curve; 0.711, 95% CI; 0.570–0.851, p = 0.010). Conclusions: Procedural thromboembolisms after MT for acute ischemic stroke are significantly associated with longer procedural time and IV thrombolysis. This study suggests that patients with IV thrombolysis and longer procedural time (≥71 min) are at a higher risk of procedural thromboembolisms after MT for acute ischemic stroke.

Long-term Clinical Outcomes of Elective Carotid Artery Stenting in Patients Undergoing Maintenance Hemodialysis

Objective Carotid artery stenting (CAS) in patients undergoing maintenance hemodialysis is characterized by high complication rates. These patients are excluded from clinical trials of CAS. The purpose of our retrospective study was to investigate the long-term clinical outcomes of CAS in patients undergoing maintenance hemodialysis. Methods CAS was performed under local anesthesia. The technical success rate, periprocedural complications, 30-day major vascular event rate (stroke, myocardial infarction, and/or death), 3-month morbidity and mortality rates, and 5-year survival probability were investigated. Patients Nineteen patients undergoing maintenance hemodialysis were identified. Results The mean age of the patients was 69 years. Periprocedural complications occurred in two patients (confusion following CAS in one and transient hemiparesis in the other). Complete neurological recovery was achieved in both patients. No major cardiovascular events occurred within 30 days after CAS. Asymptomatic intracranial hemorrhage only occurred in one patient, and seven patients died during the follow-up period at a mean of 3.5 years after the procedure (range, 6 months to 8 years). No permanent neurologic deficit remained in the patient with intracranial hemorrhage. The causes of death were cardiovascular disease (n = 4), cancer (n = 2), and pneumonia (n = 1). No patients died of stroke. The 5-year survival probability in patients undergoing maintenance hemodialysis was 57%. Conclusion CAS in maintenance hemodialysis patients may be feasible and effective for the prevention of stroke with proper case selection, appropriate technique and strict perioperative management. The most common causes of death during the follow-up of maintenance hemodialysis patients were diseases other than stroke.

A case of tandem stenoses at the proximal common and internal carotid arteries treated with transbrachial stenting: a case report

The transfemoral approach is a common technique for carotid artery stenting. However, it has the risk of distal embolism when stenting for a stenosis of the proximal common carotid artery because of poor stability of the guiding catheter resulting in difficulty in setting the embolic protection device prior to stenting. We present a novel therapeutic approach and technique for the treatment of tandem carotid stenoses including the proximal common carotid artery. A 63-year-old man presented with double stenoses at the common carotid artery and internal carotid artery. We used a transbrachial sheath guide that had a 6 Fr (2.24 mm, 0.088 inch) internal diameter and was 90 cm long, and was specifically designed for direct cannulation to the common carotid artery, like a modified Simmons catheter. Because the sheath guide positioned in the aortic arch made it possible to introduce safely the embolic protection device distal to the internal carotid artery stenosis without touching the plaque at the stenosis with no use of any coaxial catheters or guidewires, carotid artery stenting for tandem stenoses could be successfully carried out. The postoperative course was uneventful. In carotid artery stenting, especially for stenosis of the proximal common carotid artery, the sheath guide designed for transbrachial carotid cannulation was useful in stenting the tandem carotid stenoses.

Anatomical features of the vertebral artery for transbrachial direct cannulation of a guiding catheter to perform coil embolization of cerebral aneurysms in the posterior cerebral circulation

BACKGROUND

Transbrachial approach is an alternative technique for coil embolization of posterior circulation aneurysms. The purpose of our study was to investigate the anatomical features of the vertebral artery (VA) for transbrachial direct VA cannulation of a guiding catheter (GC) to perform coil embolization of posterior circulation aneurysms.

METHODS

Included in retrospective analysis were patients who underwent transbrachial coil embolization of cerebral aneurysms in the posterior cerebral circulation by direct VA cannulation of a GC from 2007 to 2013. Investigated were patient characteristics, preoperative sizes of aneurysms, aneurysms location, the angle formed by the target VA and the subclavian artery (AVS), and the VA diameter at the level of the fourth cervical vertebral body (VAD) in the side of the transbrachial access route.

RESULTS

Thirty-one patients with 32 aneurysms met our criteria. The locations of aneurysms were the VA (n = 16), basilar artery (BA) tip (n = 10), BA trunk (n = 3), BA superior cerebellar artery (n = 1), BA anterior inferior cerebellar artery (n = 1), and VA posterior inferior cerebellar artery (n = 1). The right brachial artery was punctured in 27 cases with 28 aneurysms as transbrachial direct cannulation of a GC, and left was in 4 cases with 4 aneurysms. The average AVS, ranging from 45° to 95°, was 77°, and the average VAD, ranging from 3.18 to 4.45 mm, was 3.97 mm.

CONCLUSION

For transbrachial direct cannulation of a GC, it seems required that the AVS is about 45° or more and the VAD is about 3.18 mm or more.