A simplified pull-through angioplasty technique without a snare device. A technical note.

The pull-through angioplasty technique allows stable wire tension and stabilization of the device during the procedure. In this technique, a guide wire is passed from one sheath to another, usually with the aid of a snare device. We describe the treatment of occlusive subclavian artery disease and lesion at the origin of the vertebral artery employing a brachiofemoral pull-through technique without using a snare device. In this technique, the guide wire is advanced from the femoral artery to the brachial artery. The guide wire is directly inserted into the sheath placed at the brachial artery. The brachial artery is compressed proximal to the point of sheath insertion to prevent bleeding. The sheath is extracted temporally and the guide wire is caught outside of the body. The sheath is then introduced again through the guide wire. We used the pull-through technique without a snare device in seven cases, and we were able to build the pull-through system in six of these cases without a snare device. This pull-through technique without a snare device is not difficult to use, and may reduce the time and cost of angioplasty procedures.

Central sleep apnea and associated Chiari malformation in children with syndromic craniosynostosis: treatment and outcome data from a supraregional national craniofacial center.

OBJECT: The association of Chiari malformation Type I (CM-I) with syndromic craniosynostosis (SC) in children is well established. Central sleep apnea (CSA) may subsequently occur. However, sleep studies performed in these patients have been focused mainly on assessing the severity of obstructive sleep apnea. Therefore, the incidence and management of CSA in these patients remains poorly defined. Authors of this study aimed to assess the efficacy of foramen magnum decompression (FMD) in resolving CSA, initially detected incidentally, in a small cohort of patients with CM-I and SC. METHODS: The clinical data for 5 children who underwent FMD for CSA at Alder Hey Children's Hospital between December 2007 and December 2009 were retrospectively analyzed. Outcomes were evaluated with respect to FMDs by utilizing pre- and postdecompression sleep studies. Of the 5 patients, 2 had Crouzon syndrome and 3 had Pfeiffer syndrome. RESULTS: Patient age at the time of surgery ranged from 1.1 to 12.6 years (median 4.1 years). The median postoperative follow-up was 3.6 years. Sleep studies revealed that 2 children experienced a > 80% reduction in CSAs at 1.5 and 21 months after decompression. The remaining 3 children experienced a > 60% reduction in CSAs when reevaluated between 2 and 10 months after decompression. The associated central apnea index improved for all patients. CONCLUSIONS: Findings suggested that FMD is an effective treatment modality for improving CSA in patients with SC and associated CM-I. The use of multimodal polysomnography technology may improve the evaluation and management of these patients.

Preoperative vincristine for an inoperable choroid plexus papilloma: a case discussion and review of the literature.

The authors report the case of a 14-month-old boy with a large right intraventricular choroid plexus papilloma (CPP) for which the first attempt at resection resulted in life-threatening intraoperative hemorrhage. The tumor was unsuitable for embolization, and neoadjuvant ifosfamide, carboplatin, etoposide (ICE) chemotherapy had no effect on tumor size. However, chemotherapy with vincristine, although not impacting on CT perfusion parameters, resulted in a significant decrease in tumor size, enabling complete resection with manageable blood loss. The mechanism underlying the effect of vincristine in this case is uncertain, but it is a treatment strategy that warrants further evaluation for the treatment of CPPs that are not amenable to embolization.

Carotid artery stenting for calcified lesions.

BACKGROUND AND PURPOSE: Our aim was to assess the feasibility of carotid artery stent placement (CAS) for calcified lesions. MATERIALS AND METHODS: Using embolic protection devices (EPDs), we performed 51 CAS procedures in 43 patients with severe carotid artery stenosis accompanied by plaque calcification. Before intervention, all lesions were subjected to multidetector-row CT. The arc of the circumferential plaque calcification was measured on axial source images at the site of maximal luminal stenosis, and the total volume of the plaque calcification was determined. The angiographic outcome immediately after CAS, and intra- and postoperative complications were recorded. RESULTS: The mean arc of calcification was 201.1 +/- 72.3 degrees (range, 76-352 degrees ), and the mean of the total calcification volume was 154.9 +/- 35.4 mm(3) (range, 92-2680 mm(3)). Balloon rupture occurred in 1 procedure (2.0%) at predilation angioplasty; all 51 CAS procedures were successful without clinical adverse effects. Although there was a correlation between the arc of plaque calcification and residual stenosis (r = 0.6, P < .001), excellent dilation with residual stenosis < or =30% was achieved in all lesions. There was no correlation between the total volume of calcification and residual stenosis. None of the patients developed stroke or death within 30 days of the CAS procedure. CONCLUSION: CAS by using EPDs to treat lesions with plaque calcification is feasible even in patients with near-total circumferential plaque calcification.

Direct superficial temporal vein approach for dural carotid cavernous fistula.

SUMMARY: We present an alternative endovascular approach to treat dural carotid cavernous fistulae (dural CCF) that drain only into the superior ophthalmic vein. Four cases of cavernous dural AVFs that could not be treated via the inferior petrosal vein were accessed via the direct superficial temporal vein approach through the superior ophthalmic vein. Successful embolization was documented radiographically and clinically in all patients. The trans-superficial temporal vein approach is safe and useful for inaccessible dural CCFs through the inferior petrosal sinus.

Mechanisms of perianeurysmal edema following endovascular embolization of aneurysms.

SUMMARY: After coil embolization for an aneurysm, edema surrounding the aneurysm revealed by magnetic resonance imaging (MRI) is rarely seen and is usually associated with neurological symptoms. Perianeurysmal edema was found by postoperative MRI in three out of 182 patients with cerebral aneurysm, which was treated with Guglielmi Detachable Coil (GDC), and neurological symptoms developed simultaneously. In cases where neurological symptoms improved with conservative medical treatment, a temporary increase in the volume of an aneurysm, due to coil and thrombus formation, may result in edema. In cases where symptoms were not alleviated with conservative medical treatment, persistent water-hammer effect against the residual lumen of the aneurysm as well as an increase in the volume of aneurysm by hemorrhage in the aneurysmal wall may contribute to the development of perianeurysmal edema. Consideration of the mechanism of edema development by neurological symptoms, MRI findings, and angiographic findings is needed in order to select appropriate treatment.

Direct carotid puncture for the endovascular treatment of anterior circulation aneurysms.

We report the usefulness of Guglielmi detachable coil (GDC) embolization by direct carotid puncture for anterior circulation aneurysms. For all 27 patients, GDC embolization by direct carotid puncture was safely performed by using a 5F sheath introducer 5 cm long and a Tracker-38 catheter. Neurologic deficits and hemorrhage were not found in any patient during the follow-up period. If the transfemoral approach cannot be applied, GDC embolization should be considered as an alternative method.

The significance of incomplete stent apposition in patients undergoing stenting of internal carotid artery stenosis.

BACKGROUND AND PURPOSE: Incomplete stent apposition after carotid angioplasty and stent placement (CAS) is often seen but little is known about how the incomplete attachment goes after stent placement. For example, some may change into restenosis around the stent edge and some may remain unchanged. The purpose of this study is to clarify the morphologic prognosis of an incomplete stent apposition at the stent edge. METHODS: CAS was attempted on 135 consecutive stenotic lesions (124 patients). Angiograms were then evaluated immediately after the procedure. An incomplete stent apposition at stent edge was found in 15 patients, and all of them were followed up by angiography and MR imaging with antiplatelet therapy. RESULTS: No ischemic event caused by the lesions occurred during the mean follow-up period of 11 months (from 4 to 32 months). The angiography findings of 15 lesions at a mean of 8.8 months (from 2 to 28 months) after CAS showed that all remained unchanged. No patients required any additional intervention. No new ischemic lesions were detected in any of the 15 patients who underwent follow-up MR imaging at a mean of 10 months (from 2 to 32 months) after CAS. CONCLUSION: In this study, the existence of a segment of incomplete stent apposition had no adverse morphologic or clinical effect.

Spontaneous improvement of persistent ulceration after carotid artery stenting.

BACKGROUND AND PURPOSE: Because carotid plaque ulceration is associated with an increased risk of cerebral embolism, residual carotid plaque ulceration directly around a stent (persistent ulceration) after carotid angioplasty and stent placement (CAS) could still be a risk factor for a stroke. The purpose of this study is to understand the morphologic and clinical prognosis of persistent ulceration. PATIENTS AND TECHNIQUES: CAS was attempted on 91 consecutive stenotic lesions (80 patients). Of these, 54 lesions (48 patients) had ulceration before CAS. Angiograms were evaluated immediately after the procedure. Persistent ulceration was found in 34 lesions (30 patients). The mean depth and length of persistent ulcers were 2.1 mm (range, 1-4.7 mm) and 8.9 mm (range, 1.5-22 mm), respectively. All patients with persistent ulceration were followed with antiplatelet therapy. RESULTS: No ischemic event due to the lesions occurred during the mean follow-up period of 25.5 months (range, 3-48 months). Angiography on 25 lesions (21 patients) at a mean of 5.8 months (range, 1-21 months) after CAS showed that persistent ulceration disappeared in 12 lesions (48%), improved in 11 lesions (44%), and remained unchanged in 2 lesions (8%). Nine lesions (36%) showed restenosis, which were < or =30% and did not require any additional intervention. New ischemic lesions were not detected in any of the 14 patients (17 lesions) who underwent follow-up MR imaging at a mean of 9 months (range, 1-32 months) after CAS. CONCLUSION: We conclude that persistent ulceration after CAS improves spontaneously and is not a risk factor for cerebral embolism.