Unique percutaneous direct puncture technique for occlusion of a hypoglossal canal dural arteriovenous fistula.

PURPOSE: To report percutaneous transcranial puncture, embolization and occlusion of a very symptomatic hypoglossal canal/anterior condylar vein dural arteriovenous fistula (DAVF) using syngo iGuide navigational software in a patient in whom transarterial and transvenous embolization and surgery had failed. METHODS: After unsuccessful arterial and venous embolization and surgical treatment of a symptomatic hypoglossal canal DAVF, a 47-year-old man was transferred for further management. With exquisite anatomic detail provided by C-arm cone-beam computed tomography (CBCT) equipment (Artis zee Biplane, Dyna CT VC21H, Siemens Healthcare GmbH, Germany) and syngo iGuide needle guidance navigational software (Siemens Healthcare GmbHy) for planning a safe direct approach, the hypoglossal/anterior condylar vein, the dominant outflow vein of the fistula, was needle punctured percutaneously at the hypoglossal foramen and occluded with ethylene vinyl alcohol copolymer liquid embolic agent (Onyx, Medtronic, Minneapolis, Minnesota, USA) after placing two anchoring platinum coils (Target detachable coils, Stryker Neurovascular, Fremont, California, USA). RESULTS: After a year of progressively severe left eye proptosis, chemosis and increased intraocular pressure, the symptoms quickly subsided after this embolization and the patient was symptom free at his 3-month and later checkups. CONCLUSION: With guidance and imaging provided by CBCT and syngo iGuide navigational software, an otherwise untreatable DAVF was successfully embolized and obliterated by an aggressive unique percutaneous trans-cranial needle puncture of the dominant outflow vein in the hypoglossal canal.

The Casper carotid artery stent: a unique all metal micromesh stent designed to prevent embolic release.

BACKGROUND: Stroke due to the release of embolic debris during the placement of a stent to correct carotid artery stenosis is a constant procedural and peri-procedural threat. The new all metal Casper stent has been created with two layers of nitinol, the inner layer of which has pores diminutive enough to prevent embolic release. OBJECTIVE: To evaluate the safety, effectiveness, and utility of the double layer nitinol Casper carotid artery stent in the treatment of patients with severe carotid artery stenosis. METHODS: 19 patients with severe internal carotid artery stenosis, 14 symptomatic and 5 asymptomatic, were treated with the Casper stent. After stent placement, angiographic and cone beam CT images were recorded in all patients. RESULTS: The unique low profile delivery system allowed for easy stent placement, re-sheathing, and repositioning of the stent. The large cell external layer produced excellent apposition to the artery wall. The inner layer prevented prolapse of atherosclerotic debris through the device. Plaque coverage was achieved; residual stenosis ranged from 0% to 20%. Long term angiographic follow-up in 5 patients showed wall apposition of the device covering the lesion and no restenosis. There were no procedure related complications. Two patients experienced a delayed ischemic stroke, likely related to inconsistent medical management. CONCLUSIONS: The Casper has been an excellent stent for the treatment of internal carotid artery stenosis and its internal micromesh layer has been effective in preventing plaque prolapse. It provides the flexibility of large cell stents and the inner layer provides maximum protection against plaque prolapse.