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SUMMARY: Stenosis of the subclavian artery proximal to the origin of the internal mammary artery (IMA) used for coronary artery bypass grafting may produce flow reversal (steal syndrome) and cause myocardial ischemia. We present three cases of subclavian artery stenosis proximal to the IMA before and after CABG. The first case developed symptomatic myocardial ischemia resulting from a variant of coronary-subclavian steal syndrome. The second case had asymptomatic subclavian artery stenosis proximal to the IMA used for CABG. In the third case we planned to perform CABG using the left IMA to treat cardiac ischemia. All of the patients were successfully treated by stent placement without the use of a protection device. In the first and second cases, cardiac ischemia did not appear during balloon inflation of the subclavian artery and no embolic complication occurred. In the third case, CABG was performed six months after stenting. Subclavian artery stenting is a valid alternative to surgical treatment to restore the flow to the IMA before or after CABG.

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76 consecutive patients with 78 unruptured cerebral aneurysms underwent endovascular therapy from July 1999 to May 2004 in our institute. For the wide-necked aneurysms, the remodeling technique, double microcatheter technique, or stent-assisted coil embolization was used, while a parent artery occlusion or covered stent was applied for the giant or fusiform aneurysms. Immediate angiographical results demonstrated 33 complete occlusions, 26 neck remnants, and 14 dome fillings. Four cases were treated with parent occlusion or stenting only, and one case was not treated with embolization but with clipping due to the rupture of the aneurysm during coil embolization. Immediate angiographic findings demonstrated that in aneurysms between 5 to 10 mm, the rate of complete occlusion was 48%, that of neck remnants 33%, and that of dome fillings 27%. In aneurysms between 11 to 25 mm, the rate of complete occlusion was 14%, that of neck remnants 28%, and that of dome fillings was 58%. In the angiographic follow-up results, all aneurysms smaller than 5 mm showed complete occlusion. In aneurysms between 5 to 10 mm, 74% of the aneurysms showed complete occlusion, and 21% showed neck remnants, and 5% showed dome filling. In aneurysms between 10 to 24 mm, 25% showed complete occlusion, while 75% showed dome filling. The overall mortality rate was 0% and the morbidity rate was 3.7% (2 major strokes, 1 minor stroke) at 30-days after embolization. In the clinical follow-up study, one case of a large basilar tip aneurysm caused a fatal rupture 28 months after the initial embolization. Endovascular therapy was performed on the unruptured aneurysms and was found to be an acceptable treatment, except for durability in cases of large aneurysms.

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SUMMARY: Eighteen patients with intracranial vertebrobasilar stenosis and occlusion were treated by PTA or stenting. In 11 of 18 cases, only PTA was performed and in seven of 18 cases, we used stents. The mean stenosis before and after PTA/stenting was 82.8% and 22.3%, respectively. In 11 cases of PTA only, the stenotic rate decreased from 81.8% to 29.6%, while 85.0% of the stenotic rate remarkably reduced to 6.0% in seven cases of stenting. The 30 days morbidity and 30 days mortality rate were 5.5% and 5.5%, respectively. There was only one haemorrhagic complication (cerebellar haemorrhage) in cases of stenting, and no ischemic events during or after the procedures. Restenosis (more than 50% stenosis) occurred in four of 18 cases(22.2%) during mean followup period of 12 months. Two patients with VA occlusion before treatment, developed restenosis and reocclusion. Complete total occlusion seems to be a high-risk lesion and strict follow-up is required. In this study, PTA/stenting for intracranial vertebrobasilar artery stenosis or occlusion is an effective treatment, but strict indications may be required because procedure-related 30 days morbidity rate was 5.5% in addition to unclear natural history.

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SUMMARY: We perfomed carotid artery stenting(CAS) in 215 patients from August 1997 to October 2003 mainly using the distal protection technique. Our technique and clinical results are described in this paper.

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SUMMARY: The number of successful case reports with percutaneous transluminal angioplasty (PTA) / stenting for intracranial atherosclerotic stenoses is recently increasing with the advent of flexible coronary stents. However, it is not well known whether the perforating artery is occluded or not after stent placement in the atherosclerotic stenotic vessels. We investigated this issue using five New Zealand white rabbits. We deployed stainless steel stents in the atherosclerosis-induced abdominal aorta across the lumbar artery in which the diameters of the abdominal arteries were similar to those of human intracranial arteries. We evaluated the patency of lumbar artery by angiography and scanning electron microscopy three months after stent placement. The lumbar arteries were patent in four out of five rabbits. However, SEM findings demonstrated stent struts were covered with thick neointima and the ostia between stent struts were partially occluded. It is possible that stent placement in the atherosclerotic arteries can cause the obliteration of the perforating arteries.

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SUMMARY: In this paper, we reviewed our cases of dural arteriovenous fistulae (dural AVFs) and analyzed periprocedural complications. In 157 procedures, we encountered 14 complications. Overall, complication rate of 9% was seen.We divided these complications into five subgroups such as cranial nerve palsy, coil-related trouble, thromboembolic complication, vessel perforation, and radiation-related trouble. There were five transient abducent nerve palsies in cases with cavernous sinus dural AVFs. There were two cases of coil unraveling and two cases of coil migration. In two cases, direct puncture of the internal jugular vein was performed to retrieve the unraveled coil by using dual microcatheter and guidewire snare technique. We encountered two thromboembolic complications. In one case, venous infarction was recognized after polyvinyl alcohol particle embolization. In two cases of vessel perforations, there were no new neurological deficits except one case with transient Gerstmann syndrome. In endovascular treatment of dural AVF, serious complications are rare and can be prevented if maximum attention is paid during the procedure.

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SUMMARY: PTA/stenting for the intracranial arteriosclerotic lesion is effective and novel treatment. Our standard technique to avoid serious complications, such as vessel rupture or acute occlusion was introduced in this paper.

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SUMMARY: Total 89 patients with cervical ICA stenosis were treated by stenting. In 74 cases of stenting, we used our blocking balloon systems to prevent distal embolism. The morbidity and the mortality rate was 4.5% and 0%, respectively.Two(3%) of 74 cases showed distal embolism when blocking balloon catheter systems(BBCS) were used, while distal embolism occurred in four (27%) of 15 cases of stenting without BBCS. On diffusion- weighted MRI (DWI), hyperintense areas were detected in seven (47%) of 15 lesions when we used BBCS only during postdilatation. On the other hand, use of BBCS during predilatation as well as postdilatation reduced hyperintense areas on DWI, which were detected in three (25%) of 12 patients. Our blocking balloon catheter system is a useful device to reduce the risk of distal embolism, especially when we use it during not only postdilatation but predilatation.

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SUMMARY: We have experienced total 116 stenting for 102 of cranio-cephalic arteries and 14 of intracranial arteries including occlusive cerebrovascular diseases, aneurysms, and fistulas.Ten complications were encountered. Three were ischemic complication, four stent migration, two restenosis, and one aneurysmal perforation during coiling across the stent strut. The mechanism and preventive method of these complications were discussed in this paper.

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SUMMARY: It is important to know the characteristics of aneurysms that tend to cause perforation and treatment of these perforations to reduce the morbi/mortality of the endovascular treatment for intracranial aneurysms. Factors leading to aneurysmal perforation were analyzed from the view points of aneurysmal status (ruptured or unruptured), size and direction of aneurysmal dome from the parent artery and treatment of perforation during GDC embolization was discussed in 105 consecutive cases. Perforation occurred in three small aneurysms (less than 3 mm in diameter or depth) where the direction of the dome is the same as that of microcatheter advancement. Perforation occurred when a microcatheter was advanced to counteract catheter recoil caused by coil deployment. Haemorrhage occurred in all cases immediately following microcatheter and coil perforation into the subarachnoid space. In all cases, bleeding was controlled by deploying the coil so that it extended from the subarachnoid space back into the intraaneurysmal cavity. In two cases, surgical clipping was required to treat the incompletely obliterated aneurysm. No additional permanent neurological deficit occurred as a result of any of the three perforations. Special care should be taken during the embolization of small aneurysms (less than 3 mm in minimal diameter) where, owing to the shape of the lesion, or fixation of a microcatheter by the stent strut, the antegrade force of the canulating microcatheter is transmitted directly toward the aneurysm dome.

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The authors describe a case of indirect carotid cavernous fistula (CCF) appearing five months after embolization for traumatic direct CCF, which was treated six months after the trauma. Long-term (six months) venous hypertension to the affected cavernous sinus due to direct CCF and cavernous sinus thrombosis following a balloon embolization were considered as an etiology of the de novo dural arteriovenous fistula. The recurrent symptoms of CCF are usually related to detached balloon disorder, but delayed recurrence may be caused by the de novo dural AVF, if the direct CCF was treated in the chronic state.

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We treated a patient in whom a left retrosplenial lesion resulted in memory impairment and spatial disorientation. A 31 year old, right handed man was admitted to our hospital after the sudden onset of headache. He was alert, attentive and cooperative, and showed no motor or sensory deficits. Although intelligence was preserved, memory was obviously deficient. The patient proceeded in wrong directions after he left his hospital room and subsequently his home. Neuroimaging revealed a subcortical hematoma in the left cingulate isthmus, while single-photon emission computed tomography demonstrated decreased perfusion in the splenium and left parietal lobe.

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SUMMARY: 110 patients with extracranial ICA stenosis were treated by PTA or stenting. In 21 of 55 cases of only PTA and in 40 of 55 cases of stenting, we used our blocking balloon systems to prevent distal embolism. The morbidity and the mortality rates were 5.4% and 0%, respectively. There was only one embolic complication in cases of PTA or stenting where blocking balloon systems were used. In contrast, distal embolism occurred in 3 of 34 cases of PTA without blocking balloon systems (one symptomatic case) and in 4 of 15 cases of stenting without blocking balloon systems (3 symptomatic cases). Our blocking balloon catheter system is a useful device to reduce the risk of symptomatic distal embolism.

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SUMMARY: Fourty-five cases of intracranial atherosclerotic stenoses greater than 70% for intradural lesions or 60% for extradural lesions were treated by PTA or stenting. The stenotic lesions were successfully dilated in 44/45 patients and future stroke was prevented during a mean 29 month follow-up period. Stenotic ratio significantly reduced in stent-treated group compared with PTA-treated group and stenting was effective for cases refractory to PTA, such as elastic recoil or restenosis. However, stenting had its own drawbacks, such as difficulty in delivery, migration, and acute thrombosis.

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This 68-year-old woman underwent a distal gastrectomy for gastric cancer in August 1994. A presumed meningioma of the falx was found incidentally on a staging examination of the gastric cancer, but the meningioma was not treated with surgery. Instead, after gastrectomy the patient received tegafur as adjuvant chemotherapy until February 1996, when she was readmitted to the hospital because of loss of appetite and emaciation but with no recurrence of the gastric cancer. A computerized tomography scan obtained during this second admission showed no change in the meningioma. To improve her general condition, tegafur was discontinued and she was started on a course of the antiestrogen agent mepitiostane. Administration of mepitiostane for approximately 2 years resulted in a marked regression (73%) of the meningioma. This is the first reported case of a presumed meningioma that regressed as a result of use of the antiestrogen agent mepitiostane.

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The efficacy of repeated percutaneous transluminal angioplasty (PTA) and carotid endarterectomy (CEA) was examined in patients with restenosis after PTA for carotid stenosis. After percutaneous transluminal angioplasty (PTA) for 63 cases of internal carotid stenoses 13 cases of restenosis appeared. They were treated by PTA or carotid endarterectomy. The treatment was chosen by the patient after explanation of each treatment. We initially treated seven patients by repeat PTA and six by carotid endarterectomy. The degree of stenosis improved from 82% to 30% on average after repeated PTA. However, one patient in the PTA group had restenosis, and carotid endarterectomy was then performed. The other cases also had restenosis and were treated by PTA. The six cases treated by carotid endarterectomy were successfully treated without difficulty. The success rate of PTA was 5/7 (71%) in the restenosis cases. Patients with a greater residual stenosis after initial PTA had significantly more frequent restenosis. Repeat PTA and CEA both appeared effective treatment for restenosis after initial PTA, although PTA had a restenosis rate similar to that of initial PTA.

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A 57-year-old female was admitted to our hospital because of headache, nausea, and vomiting. Head CT scan demonstrated subarachnoid hemorrhage. Cerebral angiography showed the absence of the right internal carotid artery, and skull base CT of the bone window level revealed the absence of the right carotid canal. The right middle cerebral artery (MCA) and anterior cerebral artery (ACA) were opacified from the left internal carotid artery. The right A1 portion was hypoplastic and the distal portion of the right M1 portion was replaced by several minute complicated anastomotic vessels connected to the right M2 portion. The right MCA territory was mainly supplied by collateral flow from the right ACA and the right posterior cerebral artery via the leptomeningeal anastomosis. These was neither aneurysm nor arteriovenous malformation. The second angiography, 1 week after the initial angiography, showed the same hemodynamic pattern and aneurysms were not found. We diagnosed the patient as agenesis of the right internal carotid artery and the etiology of subarachnoid hemorrhage was suspected to be a rupture of the anastomotic vessels between the right M1 and M2. She was discharged on the 21st hospital day without any neurological deficit.

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SUMMARY: We report 3 cases of internal carotid artery (ICA) stenosis with thrombus. The initial symptom is transient ischemic attack (TIA) in 1 case, and cerebral infarction due to artery-to-artery embolism in 2 cases.We started anticoagulation and antiplatelet therapy after the angiography on admission in all cases. Carotid endarterectomy (CEA) was performed in 1 case after confirming the disappearance of the thrombus 1 month after the initial attack, although small cerebral embolic infarction happened during this period. In the other cases, percutaneous transluminal angioplasty (PTA) and stenting was performed using the protective technique about 2 weeks after the initial attack without embolic complication. Postoperative angiography showed sufficient dilatation. It seemed that PTA/stenting using the protection system was one of the alternatives for ICA stenosis with thrombus.

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SUMMARY: Wedge pressure of the occluded major cerebral artery (distal pressure beyond the occlusion) was measured to estimate the residual cerebral blood flow in thirteen patients with acute ischemic stroke. There existed the relationship that patients with higher wedge pressure tolerated longer ischemic insults than those with lower wedge pressure. Wedge pressure is measured with minimum time loss before starting thrombolytic therapy and may be a good indicator to estimate the brain tissue reversibility.

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SUMMARY: This paper will overview our results of endovascular therapy (PTA or stenting) for cervical ICA stenosis and discuss the advantages and disadvantages of each treatment. 60 cases with 62 lesions were treated with PTA 68 times, while 36 cases with 37 lesions were treated with stenting 37 times. A total of 99 lesions were treated with PTA or stenting 105 times. In the PTA group arterial stenosis improved from 76.4% to 21%. In the stent group the stenosis improved from 82.3% to 8.3%. The morbidity rate was 2/60 (3.3%) in PTA group, although two cases had minor neurological deficits, while in stent treated group, morbidity rate was 1/36 (2.8%), although it showed one major neurological deficit. Mortality was 0% in each group. The restenosis rate in PTA group was 15/58 (26%), while it was 0/20 (0%) in stent treated group. Stenting brings significant reduction of stenosis and reduces the rate of restenosis compared to PTA. However, stenting has its own disadvantages such as hypotension and distal kinks when deployed in tortuous ICA stenosis.