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Craniocervical junction arteriovenous fistula (CCJ AVF) is a rare vascular disorder. Direct surgery for CCJ AVF is generally reported to have better outcome compared to endovascular treatment. However, no certain consensus has been obtained so far. We report a case of radicular CCJ AVF treated by transarterial embolization that resulted in a good outcome. A 69-year-old man presented with subarachnoid hemorrhage primarily in the posterior cranial fossa. Based on digital subtraction angiography showed radicular CCJ AVF with varix. Transarterial embolization was performed with n-butyl-2-cyanoacrylate on day 17 after onset and successfully cured. The neurovascular anatomy of CCJ AVF is complicated, but endovascular treatment may be a treatment option with detailed understanding of angioarchitecture and selective endovascular procedure.

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True deep femoral artery aneurysms are a rare abnormality of the human vascular system and account for approximately 0.13% of all peripheral arterial aneurysms. We report a 66-year-old man with a ruptured deep femoral artery aneurysm and a pulsating hematoma. The patient underwent urgent endovascular embolization of the aneurysm-supplying artery. Then, 4 days later, in connection with the residual hematoma, which caused severe discomfort to the patient, and also due to the high risk of septic complications in the area of the hematoma, it was decided to perform an open aneurysmectomy and deep femoral artery ligation.

A deep femoral artery aneurysm (a bulge in a blood vessel caused by a weakness in the blood vessel wall) is a rare abnormality of the human vascular system. A ruptured aneurysm can cause serious health problems such as bleeding, hemorrhagic shock and even death. We report a 66-year-old man with a ruptured femoral artery aneurysm. The patient underwent urgent intravascular plugging of the artery supplying the aneurysm. Then, 4 days later, in connection with the residual hematoma, which caused severe discomfort to the patient, and also due to the high risk of complications, it was decided to perform an open operative excision of the aneurysm. The postoperative period and 2-year follow-up were uneventful.

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PURPOSE: The aim of this study is to evaluate the value of selective intra-arterial cone-beam computed tomography angiography (CBCTA) relative to conventional computed tomography angiography (CTA) in understanding visceral artery aneurysm (VAA) morphology, and its impact on treatment planning. MATERIALS AND METHODS: Between January 2017 and August 2021, all patients who had a diagnosis of VAA and underwent intraoperative CBCTA imaging were retrospectively reviewed. Impact on treatment decisions, optimal C-arm angulations derived from CBCTA, and additional radiation exposure were reported. Two blinded independent reviewers qualitatively reviewed CBCTA and conventional CTA images. A 5-point Likert scale (1=poor image quality, 5=excellent image quality) was used to assess the overall image quality of each modality. Number of vessels arising from the aneurysm sac was counted. RESULTS: A total of 16 patients had a diagnosis of VAA during the study period, of whom 10 patients had intraoperative CBCTA and conventional CTA available for review. Out of 10 patients, 7 underwent successful endovascular treatment, 2 were deemed not amenable for endovascular embolization based on intraoperative CBCTA findings, and 1 had resolved pseudoaneurysm. Total fluoroscopy time and radiation dose (dose area product [DAP] and skin dose) for all procedures were 27.7 ± 19.9 minutes, 28 362 (±18 651) µGy*m2, and 1879 (±1734) mGy, respectively. Radiation exposure from CBCTA (DAP and skin dose) was 5703 (±3967) µGy*m2 and 223.6 (±141.3) mGy, respectively. In patients who underwent endovascular treatment, the proportional DAP from CBCTA was 18.3% (±15.3%) of the total procedural radiation dose. Qualitative rating of overall image quality of CBCTA images was superior to CTA images (mean score: 4.55 vs 3, p<0.001). More branch vessels arising from the VAA were identified by all reviewers in CBCTA as compared with conventional CTA (median, min-max: 3, 0-4 vs 2,1-3 vessels). CONCLUSION: Intraoperative CBCTA after selective intra-arterial contrast injection, with better spatial resolution, provided better delineation of visceral aneurysm morphology as compared with conventional, intravenous CTA and enabled optimal treatment planning at a reasonable additional radiation exposure. CLINICAL IMPACT: Visceral artery aneurysms (VAA) are often diagnosed incidentally by conventional computed tomographic angiography (CTA). Endovascular treatment typically requires selective angiographies at multiple projections to better understand aneurysm morphology, location, and efferent branch vessels. Intra-arterial cone-beam CT angiography (CBCTA) for VAA has the advantage of selective contrast opacification, better spatial resolution, and three-dimensional/multi-planar visualization of aneurysm morphology. In addition, CBCTA enables identification of optimal C-arm working projection for subsequent endovascular treatment. The aim of this study is to evaluate the value of intraoperative CBCTA relative to conventional CTA in understanding visceral artery aneurysm morphology and its impact on treatment planning.

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Arteriovenous fistulas (AVF) of the kidney are uncommon. They may be acquired, idiopathic or arise of congenital arteriovenous malformation. Acquired renal AVF are mostly iatrogenic due to the increasing number of mini-invasive nephron surgery. We report a case of renal AVF in a 65-year-old woman previously treated with left robotic partial nephrectomy (PN), which was successfully treated by endovascular coiling.

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BACKGROUND: Bow hunter's syndrome (BHS) is a rare condition characterized by mechanical impingement of a vertebral artery (VA) during neck rotation followed by vertebrobasilar insufficiency. Posterior fusion is a typical surgical method for BHS. OBSERVATIONS: The case of a 70-year-old Japanese man who presented with presyncope that occurred during right cervical rotation is reported. Given the possibility of vertebrobasilar insufficiency, digital subtraction angiography and computed tomography angiography were performed and showed a hypoplastic right VA and severe stenosis of the left VA over the occiput (O)-C2 level. The blood flow of the left VA was interrupted by right cervical rotation, with resumption of blood flow on left cervical rotation. BHS was diagnosed, and posterior fusion at the O-C2 level was performed. Immediately after implant fixation, selective arteriography confirmed disruption of blood flow in the left VA. The rods were removed immediately; resumption of blood flow was confirmed; and the rods were refixed, anatomically bent with slight left cervical rotation. Then, sustained blood flow in the left VA was confirmed. LESSONS: Posterior fixation for BHS can induce VA occlusion due to minor changes in cervical spine alignment. Intraoperative selective arteriography is a necessary tool to identify occlusion of the affected VA.

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INTRODUCTION: Congenital pelvic malformations are rare and represent a difficult therapeutic challenge. Scrotal arteriovenous malformations are quite unusual, with only a few such cases reported in the literature. Only one case of scrotal malformation? due to an arteriovenous fistula resulting in azoospermia has been described. PRESENTATION OF CASE: The two-phase strategy adopted in that case permitted complete treatment of a large-sized malformation that was served by 4 main blood confluences. DISCUSSION: Angio-CT performed using reconstructions with MIP and SSD algorithms provided more detailed data about the extension of the afferents and efferents of the arteriovenous malformation, thus enabling us to plan the endovascular treatment of the lesion. CONCLUSION: A multidisciplinary approach is mandatory to achieve good results in these cases.

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PURPOSE: Describe the clinical finding and course of treatment in patients with a sudden decrease in visual function due to an acute occlusion of the arteria centralis retinae. Patients were primarily indicated for selective angiography with thrombolysis of the ophthalmic artery. MATERIALS AND METHODS: Medical documentation of two patients with acute central retinal artery occlusion with a time duration of up to 5 hours was evaluated retrospectively. The diagnosis of central retinal artery occlusion was determined on the basis of a detailed ophthalmological examination in arteficial mydriasis. The initial best-corrected visual acuity (BCVA) were hand movement in front of the eye with uncertain light projection in first patient and no light perception in the second patient. In both cases a relative afferent pupillary defect of the 4th degree was present with the onset of the ischemic macular edema and an incipient development of the cherry red spot. After evaluation of the overall condition, laboratory findings, exclusion of cancer and surgery in the last three months, a selective angiography of ophthalmic artery and thrombolysis in collaboration with the intervention radiologist were performed.   Results: First patient with a better initial visual acuity, selective angiography demonstrated a decrease in flow in the central retinal artery with subsequent improvement in haemodynamic ratios after application of 12 ml of recombinant tissue plasminogen activator (Alteplase). The BCVA improved to 1/ 60 after interventional procedure. We did not experience any serious treatment side effects during or after intervention. In the second patient, selective angiography of the intracranial arteries and internal carotids revealed the presence of an aneurysm before the ophthalmic artery. Due to the normal flow of the contralateral carotid and the filling of the intracranial vessels on the affected side via the circle of Willis, the internal carotid ligation was performed under the aneurysm. Three months after the surgery BCVA was no light perception and patient had no neurological symptomatology. CONCLUSION: Selective angiography in combination with thrombolysis appears to be a useful imaging as well as therapeutic method for acute central retinal artery occlusion. This technique allows not only to confirm the diagnosis but it can also solve problem causally and improve the visual acuity of the affected person. Sometimes it also helps to clear the cause of the closure and prevent next potential embolization into the intracranial space and possible fatal consequences of CNS involvement or even death.

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BACKGROUND/PURPOSE: To study steerable microcatheter (SM) use in moderate and highly difficult vessel selection compared to conventional pre-shaped microcatheter (CM) use. MATERIAL AND METHODS: An IRB approved, single institution analysis of 40 complex angiographic procedures with and without superselective microcatheter use during an eight-month period in 2017 was performed. Target vessels were deemed moderate or highly difficult to select based on vessel size, tortuosity, and/or angulation during non-selective initial angiography. Data collected included type of microcatheter used (SM or CM), number of microcatheters and microwires used, procedure time, radiation exposure index (dose area product/DAP), target vessel location, and time to target vessel selection (TTVS; time from device placement to vessel selection). Comparison between the SM and CM groups was performed using Wilcoxon test. RESULTS: A SM (SwiftNinja, Merit Medical, South Jordan, UT, USA) was used to select 46 vessels in 20 patients. One or more CMs were used in 20 patients to select 34 vessels. Median TTVS, number of microwires used, total procedure time, and DAP (microGray.m2) were 12 vs. 462.5 s (p < 0.0001), 0 vs. 2 (p < 0.001), and 26,948 vs. 30,904 (p = 0.15) in the SM vs. CM groups, respectively. When adjusted for body mass index (BMI) using a linear model for radiation exposure, patients in the SM group had lower radiation exposure than those in the CM group (p = 0.05). CONCLUSIONS: Utilization of a steerable microcatheter, without or with a guidewire, leads to easier and faster target vessel selection with shorter procedure times in complex vessel anatomy.

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Renal angiomyolipoma (AML), a rare benign mesenchymal neoplasm, is characterized by the presence of vessels, smooth muscle, and adipose tissue. Treatment should be considered for symptomatic patients or for those at risk for complications, in particular for retroperitoneal bleeding, which is correlated to the size of the tumor, grade of the angiogenic component, and presence of tuberous sclerosis complex. Herein, we report the case of a 39-year-old female with renal AML who was treated in a conservative approach by super-selective embolization.

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PURPOSE: A steerable microcatheter provided with a mechanism on the handle for changing the direction of the catheter tip was developed by Sumitomo Bakelite and evaluated in a clinical trial before introduction into clinical use. MATERIAL AND METHODS: The steerable microcatheter has a 2.4F/2.9-F external diameter (distal/proximal portion) and a 0.021-inch internal diameter with a dial on the proximal portion for moving the tip. In patients scheduled to undergo selective transarterial procedures, selective arteriography of target arterial branches chosen by the evaluator was performed using the steerable microcatheter during the procedure. Efficacy was evaluated based on operability (technical success, procedure time, use of guidewire, usefulness of tip mobility), and safety was evaluated based on defects and adverse events. RESULTS: Between September 2013 and October 2013, 20 patients were enrolled at four institutions. The success rate for guidewireless insertion of the steerable microcatheter into the target vessels was 96.7%, and operability was judged as good in all 20 patients. Poor tip movement was identified as a defect of the steerable microcatheter in one patient. There were no adverse events associated with the use of the steerable microcatheter. CONCLUSION: This trial confirmed that the steerable microcatheter had the utility required for medical device approval. Thereafter, it obtained marketing approval.

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BACKGROUND: Successful radiosurgery for intracranial arteriovenous malformations (AVMs) requires accurate delineation of the nidus in 3D. Exact targeting and precise equipment is needed to achieve obliteration of the nidus while minimizing toxicity to the surrounding brain. In some micro-AVMs and poorly visible AVMs we have used cone beam CT angiography (CBCTA) with selective and super-selective angiography where a micro-catheter is advanced into the feeding arteries- to assist with nidus definition for CyberKnife radiosurgery planning. METHODS: Four patients who had AVMs inadequately visualized with MRI, MRA, CT, CTA, and dynamic CT angiography (dCTA) were identified for selective angiography (2 had super-selective angiography) for CyberKnife radiosurgery. The mean age at the time of treatment was 45 years (range: 22 - 71 years). All patients had suffered prior hemorrhage and were deemed inoperable. Super-selective angiography was done under general anesthesia to minimize motion artefact and the risk of arterial dissection. Angiography was performed using the biplane angiographic suite (ArtisQ; Siemens). Cone beam reconstructions were performed using DynaCT software. For each scan, volumetric data was acquired over 20 seconds in a single rotation of the C-arm mounted flat-panel detector cone-beam CT system. The data set was imported into the CyberKnife TPS and co-registered with the treatment planning CT, T2 MRI and Toshiba dCTA. Delineation of the AVM nidus was performed by the multi-disciplinary AVM team. RESULTS: There were no adverse events related to the angiography or radiosurgery treatment. CBCTA data sets created using DynaCT were accurately co-registered with the treatment planning scans in the CyberKnife treatment planning system (Multiplan). For all 4 patients, feeding arteries, draining veins and nidi were clearly visualized and used to develop radiosurgery plans. Mean nidus size was 0.45cc (range: 0.07 - 1.00cc). CONCLUSIONS: For intracranial micro-AVMs and AVMs otherwise poorly visualized using DSA, MRA, CTA or dCTA, selective and super-selective CBCTA images (created using DynaCT) can be successfully imported into the CyberKnife TPS to assist in nidus delineation. Advancement of a micro-catheter into the feeding arteries to allow continuous contrast injection during volumetric scanning constitutes super-selective CBCTA. This technique provides superior visualization of micro-AVMs and should be utilized for radiosurgery planning of poorly visualized AVMs.

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OBJECTIVES: The objective is to describe the clinical, radiographic, echocardiographic and angiographic findings in dogs with systemic-to-pulmonary arteriovenous fistula (SPAVF). ANIMALS: Thirteen medical records of client-owned dogs with a diagnosis of SPAVF were reviewed/analysed. METHODS: This is a retrospective study of case records. Thoracic radiography, transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), three-dimensional TEE, intracardiac echocardiography, fluoroscopy-guided or computed tomography (CT) angiography were carried out. RESULTS: Based on the TTE, SPAVF was identified in seven of the included dogs. In eight cases, TEE and angiography were both performed and confirmed the diagnosis. Computed tomography angiography was performed in three dogs. A case was diagnosed by TEE alone, another one by three-dimensional TEE and the latter by intracardiac echocardiography. CONCLUSIONS: Transthoracic echocardiography identified seven cases of SPAVF, while definitive diagnosis in the remaining dogs required selective angiography or computed tomography angiography.

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OBJECTIVE: To explore the diagnostic value of digital subtraction angiography (DSA) and the effectiveness of endovascular treatment for a post-pancreaticoduodenectomy hemorrhage (PPH). RESULTS: During the DSA examination, positive results were found in 29 patients, yielding a positive rate of 69.0%. The manifestations of the DSA examination included contrast medium extravasation, pseudoaneurysm, and artery walls coarse. All 29 patients with positive results underwent endovascular treatment, including transartery embolization (TAE) in 28 patients and covered stents placement in one patient. The technical success and clinical success rates were 100% and 72.4%, respectively. Re-bleeding occurred in 8 of the 29 patients after the first treatment (27.6%). The mortality of PPH was 17.2% (5 of 29). Two of the five PPH patients died following severe infections, and three died from multiple organ failure. MATERIALS AND METHODS: A DSA examination was conducted using clinical and imaging data of 42 patients, and endovascular treatment for delayed PPH was retrospectively analyzed. CONCLUSIONS: DSA examination is a minimally invasive and rapid method for the diagnosis of delayed PPH. For patients with positive DSA results, endovascular treatment can be performed rapidly, safely, and effectively. Therefore, the DSA examination and endovascular treatment could be considered a preferred treatment approach for delayed PPH.

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BACKGROUND: Ablation in aortic cusps could be necessary in up to 15% of the patients, especially in para-Hisian atrial tachycardia and ventricular arrhythmias arising from outflow tracts. Risk of coronary damage has led to recommendation of systematic coronary angiography (CA) during the procedure. Other image tests as intravascular (ICE) or transesophageal echocardiography (TEE) have been proposed. Both methods have limitations: additional vascular access for ICE and need for additional CA in some patients in case of TEE. We describe an alternative method to assess relation of catheter tip and coronary ostia during ablation in aortic cusps without additional vascular accesses by performing selective angiography with the ablation catheter. METHODS AND RESULTS: We prospectively evaluated 12 consecutive patients (69.3 ± 8.5, 6 female) who underwent ablation in right (1), left (5), and noncoronary cusps (6). We performed angiography through the ablation cooled tip radiofrequency catheter at the ablation site. Ablation was effective in 91.6% of the patients (3 patients needed additional ablation out of coronary cusps: pulmonary cusp, right ventricular outflow tract (RVOT), and coronary sinus and 1 patient underwent a second procedure because recurrence). No complications occurred neither during procedure nor follow-up (6.2 ± 3.8 months). No technical problems occurred with the ablation catheter after contrast injection. CONCLUSION: Selective angiography through a cooled-tip radiofrequency ablation catheter is feasible to assess relation of coronary ostia and ablation site when ablation in aortic cusps. It allows continuous real-time assessment of this relation, avoids the need for additional vascular accesses and no complications occurred in our series.

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Vessel-selective dynamic angiograms provide a wealth of useful information about the anatomical and functional status of arteries, including information about collateral flow and blood supply to lesions. Conventional x-ray techniques are invasive and carry some risks to the patient, so non-invasive alternatives are desirable. Previously, non-contrast dynamic MRI angiograms based on arterial spin labeling (ASL) have been demonstrated using both spoiled gradient echo (SPGR) and balanced steady-state free precession (bSSFP) readout modules, but no direct comparison has been made, and bSSFP optimization over a long readout period has not been fully explored. In this study bSSFP and SPGR are theoretically and experimentally compared for dynamic ASL angiography. Unlike SPGR, bSSFP was found to have a very low ASL signal attenuation rate, even when a relatively large flip angle and short repetition time were used, leading to a threefold improvement in the measured signal-to-noise ratio (SNR) efficiency compared with SPGR. For vessel-selective applications, SNR efficiency can be further improved over single-artery labeling methods by using a vessel-encoded pseudo-continuous ASL (VEPCASL) approach. The combination of a VEPCASL preparation with a time-resolved bSSFP readout allowed the generation of four-dimensional (4D; time-resolved three-dimensional, 3D) vessel-selective cerebral angiograms in healthy volunteers with 59 ms temporal resolution. Good quality 4D angiograms were obtained in all subjects, providing comparable structural information to 3D time-of-flight images, as well as dynamic information and vessel selectivity, which was shown to be high. A rapid 1.5 min dynamic two-dimensional version of the sequence yielded similar image features and would be suitable for a busy clinical protocol. Preliminary experiments with bSSFP that included the extracranial vessels showed signal loss in regions of poor magnetic field homogeneity. However, for intracranial vessel-selective angiography, the proposed bSSFP VEPCASL sequence is highly SNR efficient and could provide useful information in a range of cerebrovascular diseases. © 2016 The Authors. NMR in Biomedicine published by John Wiley & Sons Ltd.

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A case of double ophthalmic arteries arising from the internal carotid artery with unique features is reported. This case was discovered following in the course of time the progress of a thrombosis of the anterior cavernous sinus associated with a low-flow direct arteriovenous fistula of the superior ophthalmic vein. At different time points, the same patient underwent four angiographic studies and one computerized tomography with contrast medium. Angiographies showed that the double internal carotid artery origin of the ophthalmic artery was detectable only within a short range of time. To the best of our knowledge, this case is unique as it demonstrates that a second ophthalmic artery may lie hidden, showing itself only under particular hemodynamic requirements.

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We present two patients of univentricular physiology, who underwent diaphragmatic plication following the complication of diaphragmatic paralysis resulting from a bidirectional Glenn procedure. Over several months, complex connections developed between aortopulmonary collateral arteries, resulting in large shunts around the plication sites and an increased central pulmonary artery (PA) pressure to 14-15 mmHg. Most blood flow from these connections was reversed in the lower PAs of the affected side, reaching the contralateral lungs through the central PAs. Selective angiography identified almost all of the feeding arteries and complex connections. Aggressive coil embolization at these sites decreased the PA pressure to approximately 10 mmHg, enabling the Fontan procedure.

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Objective To evaluate the application value of DSA diagnosis and interventional therapy in gas-trointestinal hemorrhage. Methods 36 cases of gastrointestinal hemorrhage used DSA examination, according to the reason and position,26 cases of the patients that were positive of DSA opacification utilized interventional therapy with different embolic agents or vasopressin peffusion. Results 26 cases of patients in 36 had gastrointestinal hemorrhage, 12 cases of patients in 16 that have extravasation of contrast media were hemostasis by treating with embolization ther-apy and vasopressin peffusion, hemorrhage of eholecyst and biliary tract after operation,the patients of small intestinal hemorrhage, gastroduodenal hemorrhage after the operation of pancreatic carcinoma were embolized with gelfoam ,PVAand/or colis were done. The stopped bleeding immediately oceured in 84. 6% (22/26). Conclusion DSA are more valuable methods for the diagnosis of gastrointestinal hemorrhage. Arterial embolization and/or perfusion of vasoconl-rictor substance for treatment of hemorrhage of digestive tract is safe, effec is reliable.

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Bronchial artery bleeding is the most common cause of life-threatening hemoptysis. The most common underlying etiologies include tuberculosis, bronchiectasis, aspergillosis, and cystic fibrosis. Bronchial artery embolization is an important treatment for significant hemoptysis, given its high early success rate and relatively low risk compared with alternative medical and surgical treatments. In this article, the relevant anatomy and pathophysiology leading to bronchial artery bleeding is discussed, including the roles of parenchymal lung diseases and of collateral and aberrant vessels. The indications for treatment, success rate, and complication rate for bronchial artery embolization are reviewed. Preprocedure clinical stabilization and evaluation, including the roles of radiographs, bronchoscopy, and computed tomography examination are evaluated. Details of technique, including the published variety of approaches, and an emphasis on avoidance of nontarget embolization of important mediastinal structures and of the anterior spinal artery are discussed.

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Objective To explore the feasibility and efficacy of selective arterial embolization for the treatment of hemobilia occurred after biliary tract surgery.Methods The clinical data of 16 patients with massive hemobilia after biliary tract operation,who were treated in our hospital during the period from March 1989 to August 2009,were retrospectively analyzed.Conservative treatment of hemobilia was initially adopted in all patients,and,if it failed,interventional management was carried out.Emergent artery angiography was performed in all patients,which was followed by selective arterial embolization of the bleeding arteries with Gelfoam particles and coils.Results Of the total 16 cases,15 received selective arterial embolization therapy and the remaining one died.No re-bleeding occurred during a follow-up period of 8 months to 3 years.Conclusion For the treatment of arterial hemobilia occurred after biliary tract surgery,selective arterial embolization with Gelfoam particles and coils is a safe,mini-invasive and effective therapy with few complications.