Intraspinal canal platform system for coil embolization of anterior spinal artery aneurysm associated with spinal cord arteriovenous malformation: a case report and literature review

BACKGROUND

The prognosis for spinal artery aneurysms associated with spinal cord arteriovenous malformations (AVMs) is poor because of the high rupture rate of aneurysms. However, endovascular treatment remains technically difficult because the catheter system must be constructed via the small-caliber anterior spinal artery (ASA) or posterior spinal artery (PSA), which feeds functionally eloquent spinal cord. A 2.6F Carnelian HF-S microcatheter (Tokai Medical Products, Aichi, Japan) has been specifically designed to assist a 1.6F Carnelian MARVEL S microcatheter (Tokai Medical Products) as a small-profile 'platform catheter' close to the target lesion. Here we present a prenidal ASA aneurysm treated using a 2.6F Carnelian HF-S microcatheter as an intraspinal canal platform catheter and review related literature.

CASE PRESENTATION

A 50-year-old man presented with a subarachnoid haemorrhage due to cervical spinal cord AVM. Diagnostic vertebral angiography revealed the AVM supplied by the PSA originated from the right C2 segmental artery and ASA arising from the right V4 segment. Superselective angiography for each feeder was achieved through a 2.6F Carnelian HF-S microcatheter, and a prenidal ASA aneurysm was diagnosed, which was clinically consistent with haemorrhagic origin. A 1.6F Carnelian MARVEL S microcatheter was cannulated into the aneurysm through the 2.6F Carnelian HF-S microcatheter positioned at the ASA. The aneurysm coiling was successfully performed without system instability or periprocedural complications.

CONCLUSIONS

Only a few cases have described endovascular treatment for spinal artery aneurysms. To date, no reports have been published regarding the use of an intraspinal canal platform catheter to treat spinal artery aneurysms. A 2.6F Carnelian HF-S microcatheter served as a useful intraspinal canal platform catheter for coil embolization of the ASA aneurysm. This system can provide excellent accessibility and controllability for endovascular treatment of spinal artery lesions.

Simplified Transradial Access for Aneurysms Treatment: A Guiding System Using Solo Distal Access Catheter and Anatomical Considerations

OBJECTIVE

The recent shift from transfemoral access to transradial access in neurointervention has led to gaps in guiding systems. We propose a useful guiding system, the solo distal access catheter system without a conventional guiding catheter or a sheath in transradial access for aneurysms treatment. We also assessed the anatomical features required for suitable patient selection.

METHODS

We retrospectively collected data from consecutive patients with aneurysms treated with the solo distal access catheter system at our institution between April 2022 and April 2023, and evaluated the anatomical factors that appeared to affect the procedure.

RESULTS

Of the 20 patients who underwent transradial access, 11 were treated using the solo distal access catheter system, and 10 (90.9%) completed the procedure. No radial artery occlusion was detected. The entry angle of the target vessel ranged from 37° to 139°, and the mean proximal parent artery diameter was 9.34 ± 1.48 mm. A double subclavian innominate curve was observed in 3 of 5 patients whose target vessels were the right common carotid artery.

CONCLUSIONS

Using a solo distal access catheter as a guiding system for treating aneurysm proved effective and feasible with appropriate patient selection. Anatomical assessment of the entry angle of the target vessel, proximal parent artery diameter, and tortuosity may be important factors for the success of this method.

Distal Access Catheters for Coaxial Radial Access for Posterior Circulation Interventions

BACKGROUND

The neurointerventional field is moving towards transradial access (TRA). Among the favorable indications for TRA is for posterior circulation/vertebrobasilar interventions. For some neurointerventions, a triaxial system (guide catheter, distal access catheter [DAC], and microcatheter) is typically used for optimal support. We describe application of a new technique in which we forgo use of the guide catheter, using the DAC only for coaxial access via the radial approach and its potential advantages.

METHODS

A retrospective review was performed of our institutional database for cases using our coaxial distal access catheter technique for posterior circulation interventions. Patient characteristics and radiographic and clinical information were reviewed. All reviews were approved by institutional review board and ethics committee, and all patient identifiers were removed.

RESULTS

A total of 12 patients were found that met our criteria. Successful access and procedural completion was achieved in 11 of 12 (92%). Mechanical thrombectomy accounted for 7 cases; 2 of these patients were also stented via the same approach/technique. Other cases included 2 successful aneurysm treatments (1 flow diverter, 1 coil embolization), a balloon test occlusion for a cervical chordoma, and an arteriovenous malformation embolization.

CONCLUSIONS

TRA with a distal access catheter provides support equivalent to a triaxial system with a coaxial construct in the posterior circulation. This has the advantage of using a smaller system in the radial and vertebrobasilar artery without losing stability. This technique can be used effectively and safely for a variety of posterior circulation neuroendovascular interventions.

Usefulness of a distal access catheter in embolization of a short gastric artery pseudoaneurysm

A 59-year-old man was admitted to our hospital for hematemesis. A hematoma was found in the posterior wall of the stomach, but the source of bleeding was not identified. One month later, contrast-enhanced computed tomography revealed a pseudoaneurysm in the short gastric artery. Embolization of the pseudoaneurysm was difficult due to vessel tortuosity. Usage of a distal access catheter improved catheter stability and enabled successful embolization. We consider a distal access catheter to be useful for embolization of an aneurysm beyond a tortuous artery.

Optimal Guiding Catheter Length for Endovascular Coiling of Intracranial Aneurysms in Anterior Circulation in Era of Flourishing Distal Access System

Purpose

To determine the minimum required guiding catheter length for embolization of various intracranial aneurysms in anterior circulation and to analyze the effect of various patient factors on the required catheter length and potential interaction with its stability.

Materials and Methods

From December 2016 to March 2017, 90 patients with 93 anterior circulation aneurysms were enrolled. Three types of guiding catheters (Envoy, Envoy DA, and Envoy DA XB; Codman Neurovascular, Raynham, MA, USA) were used. We measured the in-the-body length of the catheter and checked the catheter tip location in the carotid artery. We analyzed factors affecting the in-the-body length and stability of the guiding catheter system.

Results

The average (±standard deviation) in-the-body length of the catheter was 84.2±5.9 cm. The length was significantly longer in men (89.1±5.6 vs. 82.1±4.6 cm, P<0.001), patients older than 65 years (87.7±7.8 vs. 82.7±4.2 cm, P<0.001), patients with a more tortuous arch (arch type 2 and 3) (87.5±7.4 vs. 82.7±4.4 cm, P<0.001), and patients with a distal aneurysm location (distal group) (86.2±5.0 vs. 82.7±6.1 cm, P=0.004). A shift in the tip location was noted in 19 patients (20.4%); there was no significant different among the 3 catheters (P=0.942).

Conclusion

The minimum required length of a guiding catheter was 84 cm on average for elective anterior-circulation aneurysm embolization. The length increased in men older than 65 years with a more tortuous arch. We could reach a higher position with distal access catheters with little difference in the stability once we reached the target location.

Forced Arterial Suction Thrombectomy Using Distal Access Catheter in Acute Ischemic Stroke

Historical innovations in mechanical thrombectomy devices and strategies for ischemic stroke have resulted in improved angiographic outcomes and better clinical outcomes. Various devices have been used, but the two most common approaches are aspiration thrombectomy and stent-retrieval thrombectomy. Aspiration thrombectomy has advanced from the traditional Penumbra system to forced arterial suction thrombectomy and a direct aspiration first-pass technique. Newer generation aspiration catheters with flexible distal tips and a larger bore have demonstrated faster and better recanalization relative to older devices. Recently, several species of distal access catheters have similar structural characteristics to the Penumbra reperfusion catheter. Therefore, we used the distal access catheter for forced arterial suction thrombectomy in three patients with acute ischemic stroke. In each case, we achieved fast and complete recanalization without significant complications. Forced arterial suction thrombectomy using a distal access catheter might provide another option for mechanical thrombectomy in patients with acute ischemic stroke.

Utilization of a Novel, Multi-Durometer Intracranial Distal Access Catheter: Nuances and Experience in 110 Consecutive Cases of Aneurysm Flow Diversion

BACKGROUND

Coaxial catheter support systems provide a safe and stable foundation in endovascular treatment of intracranial aneurysms. Increasingly, robust distal intracranial support is sought during complex neurointerventions. The AXS Catalyst 5 distal access catheter (Cat5) is a new intracranial catheter designed for improved trackability and stability. We report the first experience using Cat5 for aneurysm treatment by flow diversion.

METHODS

A single-center aneurysm database was reviewed for cases of aneurysm treatment with the Pipeline embolization device (PED) that utilized Cat5. Data were collected for patient demographics, aneurysm characteristics, procedural details, catheter positions, vessel tortuosity, and catheter related complications.

RESULTS

One hundred and ten cases of aneurysm flow diversion were successfully performed using Cat5. Patient age ranged from 21 to 86 years (mean 57 ± 12.5 years) with 84% women. Aneurysm size ranged from 2 to 28 mm (mean 5.7 ± 5.0 mm), with 97% in the anterior circulation. Twenty-four aneurysms (22%) were located beyond the ICA termination. Significant cervical carotid tortuosity was present in 26% of cases, and moderate to severe cavernous tortuosity (cavernous grade ≥2) in 45% of cases. Cat5 was tracked to the intended distal position in all cases with 100% technical success of PED implantation. No iatrogenic catheter-related vessel injury occurred, and major neurological morbidity occurred in 1 patient (1%).

SUMMARY

The Cat5 is a novel, multi-durometer cranial distal access catheter designed for use in tri-axial systems. We have demonstrated the utility of Cat5 in 110 successful cases of flow diversion with a wide range of complexity. This catheter is a new tool in the neurointerventionalist's armamentarium to achieve robust and atraumatic distal access.