Usefulness of intravascular ultrasonography for treatment of a ruptured vertebral dissecting aneurysm

We report successful stent implantation and secondary coil embolization in a wide-necked dissecting aneurysm in the vertebral artery. Intravascular ultrasonography (IVUS) showed the thrombosed pseudolumen clearly and enabled precise determination of the appropriate stent size. After stent implantation, Guglielmi detachable coil embolization was performed. Further experience is necessary to refine the technique, but IVUS may be useful to improve the safety of stent-assisted embolization.     

Emergent management of ruptured pericallosal-callosomarginal artery aneurysm using stent-assisted coil embolization

We present a case of a ruptured bilobed pericallosal aneurysm successfully treated with coil embolization through a Neuroform stent. A 48-year-old male presented with subarachnoid hemorrhage (SAH) following rupture of a previously clipped aneurysm at the bifurcation of the pericallosal and callosomarginal arteries, primarily along the pericallosal artery, Hunt and Hess grade 5. After an initial unsuccessful attempt to embolize the wide-neck aneurysm with a detachable coil, a 4×15 Neuroform stent was uneventfully deployed across the aneurysm neck followed by successful coil embolization using detachable coils. We believe this case describes the first successful use of the Neuroform stent to assist in coiling of a wide-neck pericallosal-callosomarginal aneurysm. This case highlights the expanding role of emergency endovascular therapies to manage severe SAH.     

Stent-assisted coil embolization of wide-necked renal artery bifurcation aneurysms

PURPOSE: To report preliminary results of stent-assisted coil embolization in the treatment of wide-necked renal artery bifurcation aneurysms. MATERIALS AND METHODS: Four patients (three women, one man; mean age, 54 years; range, 49-67 y) with wide-necked renal artery aneurysms were treated with dedicated neurointerventional self-expanding nitinol stent-assisted coil embolization during a 2-year period. The stent was delivered over the neck of the aneurysm, after which the aneurysm was filled with detachable coils through a microcatheter placed into the aneurysm through the stent mesh. RESULTS: Stent delivery and coil embolization was successfully completed in all cases. Complete aneurysm occlusion without coil protrusion or arterial flow compromise was obtained in all patients. A small peripheral subsegmental renal infarction necessitating no therapy was registered in one patient on postembolization computed tomography. At follow-up angiography 1 year after embolization, no aneurysm recanalization or arterial obstruction was registered. CONCLUSIONS: Our preliminary experience indicates that stent-assisted coil embolization is technically feasible and effective for the exclusion of challenging renal artery bifurcation aneurysms without the sacrifice of any branch arteries.     

Coil embolization of splenic artery aneurysm with preservation of the parent artery using a neck remodeling technique

We describe a case of a large and wide neck splenic artery aneurysm, treated by coil embolization using a balloon neck remodeling technique. The patency of the splenic artery was preserved without technical complications. This method should be considered as an alternative method for transcatheter management of splenic artery aneurysms.     

Percutaneous Management of a Hepatic Artery Aneurysm: Bleeding After Liver Transplantation

In this artical we present an unusual case of hepatic artery aneurysm bleeding due to a hepatic artery thrombosis after liver transplantation. The patient developed a recurrent hepatic artery thrombosis leading to severe graft failure in four consecutive liver transplantations. While being evaluated for a fifth transplant, stabilization of the clinical situation was attempted by interventional therapy. The first intervention was to place a stent into the hepatic artery to prevent further ischemic damage. This failed to improve graft function, but unfortunately led to the development of a pseudoaneurysm at the distal end with a subsequent rupture into the biliary tree. Bleeding was treated successfully by direct puncture and coil embolization of the aneurysm. In addition, the patient demonstrated a hemodynamically relevant portal vein stenosis on the CT scan. Stenting of the portal vein markedly improved graft function. After extensive investigations, a paroxysmal nocturnal hemoglobinuria was found to be the underlying cause of the recurrent hepatic artery thrombosis. Here we suggest that hepatic artery aneurysm bleeding is a rare but potentially fatal complication that can be successfully treated by percutaneous coil embolization. Additionally, we propose that stenting of the portal vein can lead to a significant improvement of the graft perfusion even though the hepatic artery remained occluded.     

Treatment of intracranial broad-neck aneurysms with a new self-expanding stent and coil embolization

BACKGROUND AND PURPOSE: Endovascular treatment of broad-neck intracranial aneurysms with detachable coils requires special techniques. Placement of a stent over the aneurysm neck and secondary coil embolization prevents coil migration and allows attenuated packing of the coils. However, access for the stent-delivery system can be technically limited in tortuous anatomy. We present six cases of broad-neck aneurysms treated with a new self-expanding stent and coil embolization. METHODS: Three aneurysms of the supraophthalmic internal carotid artery and three aneurysms of the basilar tip with extension to the origin of a posterior cerebral artery were treated. The stent was a new self-expanding stent with a 3F over-the-wire microcatheter delivery system. Coil embolization was performed with electrolytically detachable coils. Time-of-flight MR angiography was performed after treatment in five cases. Three other patients could not be treated with the stent because deployment was not possible after correct positioning of the delivery system. RESULTS: Access with the stent-delivery system was easy, and the aneurysm neck was covered sufficiently. After stent placement, total coil embolization was achieved in four and subtotal coil embolization was achieved in two. Parent arteries remained open, and no secondary coil migration was seen. On follow-up MR imaging, the stent was clearly visible and patency of the parent vessel and emerging branches was assessable. CONCLUSION: This new stent is a safe and efficient tool for the endovascular treatment of intracranial broad-neck aneurysms. Access to smaller vessels was easy, but the mechanism of deployment had to be improved. Follow-up MR imaging was sufficient.     

颈内动脉前壁动脉瘤支架结合弹簧圈栓塞术后再出血：病例报道

目的 报道1例应用支架结合弹簧圈栓塞治疗颈内动脉前壁宽颈动脉瘤后发生早期再出血的病例.方法 将球囊膨胀型血管内支架跨动脉瘤颈部位置并准确释放后,微导管超选进入动脉瘤内填塞弹簧圈.结果 支架成功置人,完全覆盖瘤颈,动脉瘤得到人部栓塞(90%以上),载瘤动脉及毗邻的侧支血管保持通畅,患者术后恢复良好,但是术后16 d因动脉瘤再次破裂出血导致死亡.结论 血管内支架结合弹簧圈栓塞治疗颈内动脉前肇宽颈动脉瘤是可行的,但应充分认识动脉瘤早期再次破裂出血的风险,短期随访及再治疗非常必要.     

Late Recurrence of a Hepatic Artery Aneurysm After Treatment Using an Endovascular Stent

Endovascular stent placement and coil embolization have become established options in the treatment of visceral arterial aneurysms. In this article we report the case of an 83-year-old presenting with gastrointestinal hemorrhage due to a recurrent hepatic arterial aneurysm occurring 12 years after treatment with an endovascular stent. The recurrent aneurysm had resulted from stent fracture and was successfully treated by coil embolization. To our knowledge, stent fracture complicating the endovascular treatment of a visceral artery aneurysm has not been described in the published literature. With the increasing use of metallic endoprostheses in interventional radiology, recognizing and reporting device failure are of critical importance.     

Inferior pancreaticoduodenal artery aneurysm treated with coil packing and stent placement

Two cases with a pancreaticoduodenal arterial aneurysm accompanied with superior mesenteric artery(SMA) stenosis were previously described and both were treated surgically.However,for interventional treatment,securing a sufficient blood supply to the SMA should be a priority of treatment.We present the case of a 71-year-old male with a 20 mm diameter pancreaticoduodenal arterial aneurysm accompanied by SMA stenosis at its origin.The guidewire traverse from SMA to the aneurysm was difficult because of the tight SMA stenosis;however,the guidewire traverse from the celiac artery was finally successful and was followed by balloon angioplasty using a pull-through technique,leading to stent placement.Thereafter,coil packing through the SMA achieved eradication of the aneurysm without bowel ischemia.At the last follow-up computed tomography 8 mo later,no recurrence of the aneurysm was confirmed.The pull-through technique was useful for angioplasty for tight SMA stenosis in this case.     

Transcatheter Coil Embolization of Splenic Artery Aneurysm

The purpose of this study was to evaluate clinical results and technical problems of transcatheter coil embolization for splenic artery aneurysm. Subjects were 16 patients (8 men, 8 women; age range, 40-80 years) who underwent transcatheter embolization for splenic artery aneurysm (14 true aneurysms, 2 false aneurysms) at one of our hospitals during the period January 1997 through July 2005. Two aneurysms (12.5%) were diagnosed at the time of rupture. Multiple splenic aneurysms were found in seven patients. Aneurysms were classified by site as proximal (or strictly ostial) (n = 3), middle (n = 3), or hilar (n = 10). The indication for transcatheter arterial embolization was a false or true aneurysm 20 mm in diameter. Embolic materials were fibered coils and interlocking detachable coils. Embolization was performed by the isolation technique, the packing technique, or both. Technically, all aneurysms were devascularized without severe complications. Embolized aneurysms were 6–40 mm in diameter (mean, 25 mm). Overall, the primary technical success rate was 88% (14 of 16 patients). In the remaining 2 patients (12.5%), partial recanalization occurred, and re-embolization was performed. The secondary technical success rate was 100%. Seven (44%) of the 16 study patients suffered partial splenic infarction. Intrasplenic branching originating from the aneurysm was observed in five patients. We conclude that transcatheter coil embolization should be the initial treatment of choice for splenic artery aneurysm.     

Endovascular treatment of a ruptured paraclinoid aneurysm of the carotid syphon achieved using endovascular stent and endosaccular coil placement

We herein report a case of a ruptured superior hypophyseal aneurysm of the left supraclinoid carotid artery that could not be treated with a Guglielmi detachable coil (GDC), even in combination with a supporting nondetachable balloon. After an unsuccessful attempt at surgical clipping, treatment consisted of the placement of a stent over the neck of the aneurysm, advancement of a microcatheter through the stent mesh, and endosaccular embolization with a GDC. The late clinical outcome was excellent.     

Stent management of coil herniation in embolization of internal carotid aneurysms

BACKGROUND AND PURPOSE: Coil herniation into the parent artery after detachment is an uncommon complication of embolization of the intracranial aneurysm. We report our experience with stent reconstruction of the lumen and flow of the internal carotid artery (ICA) after coil herniation during embolization for intracranial ICA aneurysms and the possible mechanisms of coil herniation.MATERIALS AND METHODS: A series of 216 consecutive patients was treated by endovascular coil embolizations for intracranial aneurysms. Of these patients, there were 9 (4 men, 5 women; 32–68 years of age) complicating with coil herniation into the ICA and undergoing stent deployment to reconstruct the ICA lumen (n = 8) or both lumen and flow (n = 1). Wide-neck aneurysms were found in 8 and narrow-neck, in 1. Aneurysms were in the posterior communicating artery (n = 5) and the paraophthalmic (n = 3) and cavernous portions (n = 1) of the ICA. Self-expandable stents were deployed in the ICA in 6; balloon-mounted stents were selected in 3.RESULTS: The causes of coil herniation appeared to be coil instability after detachment (n = 6), excessive embolization (n = 1), microcatheter-related problems (n = 1), or being pushed by subsequent coil embolization (n = 1). Endovascular stent placement to reconstruct the lumen and/or flow of the ICA was technically successful in all 9 patients; 1 needed a second stent due to further coil migration. No significant procedure-related complications were found. Clinical follow-up was 8–35 months.CONCLUSION: Coil herniation occasionally occurs during endovascular embolization of ICA aneurysms because of coil instability after detachment, excessive embolization, microcatheter-related problems, or pushing by subsequent coil embolization. In this small series, stent placement was safe and effective in the reconstruction of the arterial lumen and/or restoration of flow past a herniated coil mass.

Endovascular detachable coil embolization of intracranial aneurysms has increasingly become an alternative treatment technique to neurosurgical aneurysm clipping.¹ Despite increasing clinical experience and technologic improvements, endovascular treatment still has inherent risks of morbidity and mortality. The most common complication of endovascular embolization of the aneurysm is thromboembolic events, which may result from poor technique, endovascular devices, and/or poor flushing of the catheter systems. These complications may occur in 2.5%–28% of patients treated.^2-4 Stent-assisted aneurysm embolization is a well-known tool in the management of intracranial wide-neck aneurysms to prevent coil protrusion into the parent vessel and may allow safer and denser packing of the aneurysm sac.^5-8 However, to our knowledge, stent as a salvage procedure to reconstruct the lumen and/or blood flow of the parent artery during the procedure has not been well evaluated.The purpose of our study was to report our experience using stents to reconstruct the lumen and/or blood flow of the parent artery after coil herniation in the internal carotid artery (ICA) during embolization of intracranial ICA aneurysms and to report possible mechanisms of coil herniation.     

Endovascular treatment of a large fusiform splenic artery aneurysm with a coaxial technique using a 5-f balloon catheter and a microcatheter

A coaxial technique was introduced for successful embolization of a large fusiform splenic artery aneurysm in a vessel with a large caliber and a great degree of tortuosity. A standard 5-F angioplasty catheter was placed at the immediate afferent artery for occlusion of arterial inflow into the aneurysm, thereby preventing intraaneurysmal hypertension during embolization of the efferent segment. This was followed by coaxial microcatheterization of the immediate efferent segment for coil embolization, and then embolization of the afferent segment. It is postulated that this approach may improve the safety of embolization of large aneurysms with unfavorable morphology by decreasing the pressure on the aneurysm just after closure of the efferent segment.     

Endovascular repair of a complex renal artery aneurysm using PipelineTM Embolization Device (PED) assisted coil embolization

BackgroundWe describe the treatment of a renal artery aneurysm with complex anatomy using coils and the PipelineTM Embolization Device (Medtronic, Irvine, CA), a flow-diverting stent typically used for the treatment of intracranial aneurysms.MethodsA 62-year-old female with history of an asymptomatic right renal artery aneurysm that was discovered incidentally 10 years ago was found to have enlargement of the aneurysm (1.9cm to 2.7cm) on a repeat surveillance CT scan. She was successfully treated with combined Pipeline Embolization Device and coil embolization of the aneurysm sac.ResultsPost-procedural angiography showed complete occlusion of the aneurysm with maintenance of perfusion to the entire kidney.ConclusionPipeline^TM assisted coil embolization may be an option for parenchyma-sparing treatment of renal artery aneurysms with complex anatomy.     

Endovascular Treatment of Spontaneous Isolated Dissecting Aneurysm of the Superior Mesenteric Artery Using Stent-Assisted Coil Embolization

Spontaneous isolated dissecting aneurysm of the main trunk of the superior mesenteric artery is a rare condition. We treated a patient with this condition successfully by stent-assisted coil embolization. Intravascular stent placement may widen the indications for endovascular coiling of the aneurysmal false lumen to avoid perforation.     

创伤性假性动脉瘤的介入治疗及临床观察

目的探讨创伤性假性动脉瘤介入治疗的方法及疗效。方法对18例假性动脉瘤患者(肝动脉瘤2例,肾动脉瘤4例,脾动脉瘤1例,胸主动脉2例,周围血管9例),采用不同方法治疗。6例置入带膜支架,10例采用明胶海绵栓塞或弹簧圈栓塞,1例采用部分动脉瘤内填塞加供血动脉栓塞治疗,1例股动脉穿孔型假瘤采用压迫法。结果技术成功率100%。17例动脉瘤闭塞,症状体征消失;1例胸主动脉假瘤出现内瘘;未出现其他并发症。结论介入方法治疗假性动脉瘤安全有效。     

Delayed coil migration from a small wide-necked aneurysm after stent-assisted embolization: case report and literature review

Introduction We present a previously unreported complication following the treatment of a patient with two small, wide-necked, posterior communicating artery aneurysms.Methods Endovascular embolization of one aneurysm was performed using a stent-assisted technique. Follow-up angiography 5 months later revealed that a coil had escaped the confinement of the stent and migrated distally without occluding any arterial branches or causing symptoms. This case report demonstrates that although a rare occurrence, a coil can break loose from the stent.Discussion We discuss the potential mechanisms of this phenomenon and review the literature on stent-assisted aneurysm coiling in order to raise awareness of this event when embolizing small, wide-necked aneurysms with a stent-assisted technique.     

Traumatic pseudoaneurysm and high flow arteriovenous fistula involving internal jugular vein and common carotid artery. Treatment with covered stent and embolization

We describe the case of a 36-year-old man who presented following penetrating trauma to the neck. Angiography demonstrated a high-flow arteriovenous fistula and large false aneurysm of the common carotid artery that also had contributions from branches of the external carotid artery and the thyrocervical trunk. This was treated with a combination of a covered endovascular stent placed in the common carotid artery and coil embolization of other small feeding vessels.     

Retrograde stenting through the posterior cerebral artery in coil embolization of the posterior communicating artery aneurysm

Introduction

Protection techniques using stents or balloons are occasionally limited in coil embolization of wide-necked posterior communicating artery (PcomA) aneurysms in which the PcomA originated from the aneurysm neck at an acute angle. Here, we present two cases undergoing retrograde stenting through the posterior cerebral artery in coil embolization of the PcomA aneurysms.

Methods

To perform retrograde stenting, a microcatheter used for stent delivery was advanced from the vertebral artery (VA) to the terminal internal carotid artery (ICA) via the ipsilateral P1 and the PcomA. The aneurysm sac was selected with another microcatheter for coil delivery through the ipsilateral ICA. Coil embolization was performed under the protection of a stent placed from the terminal ICA to the PcomA.

Results

Deployment of the stent was successful in both aneurysms treated using retrograde stenting by the VA approach. Coil deployment was performed through the jailed microcatheter at first. The microcatheter was repositioned through the stent struts later in one case and another microcatheter was inserted into the sac through the stent struts in the other case. Both aneurysms were occluded properly with the coils without procedure-related complications.

Conclusion

By providing complete neck coverage, retrograde stenting for coil embolization in wide-necked PcomA aneurysms seems to be a good alternative treatment strategy, when the aneurysms are incorporating extended parts of the PcomA, and the PcomA and P1 are big enough to allow passage of the microcatheter for delivery of the stent. However, this technique should be reserved for those cases with the specific vascular anatomy.     

Enterprise支架辅助弹簧圈栓塞治疗前交通宽颈动脉瘤的临床研究

目的初步探讨和总结应用EnterPrise支架辅助弹簧圈栓塞治疗前交通宽颈动脉瘤的技术及疗效。方法收治8例前交通宽颈动脉瘤(体/颈比<1.5)患者,均采用Enterprise支架辅助水解脱弹簧圈栓塞,其中6例先放置支架覆盖动脉瘤颈再将微导管经支架网孔放入动脉瘤腔填塞弹簧圈进行栓塞,2例在微导管进入瘤腔后再释放支架进行弹簧圈栓塞。术后6～12个月进行临床和DSA随访。结果 8例全部技术成功,支架到位满意,载瘤动脉通畅,无手术并发症;其中动脉瘤完全闭塞7例,闭塞95%以上1例,患者术后均恢复良好,临床随访6～12个月无再出血及脑血栓形成,其中DSA随访6例无支架狭窄及动脉瘤再通。结论 Enterprise支架辅助弹簧圈栓塞治疗前交通宽颈动脉瘤是一种安全、可靠、有效的治疗方法,但其长期疗效仍需进一步观察。