Catheter Angiogram Research Articles

Temporary vessel occlusion in cerebral aneurysm surgery guided by direct cortical motor evoked potentials.

Temporary clipping is an important tool in the vascular neurosurgeon's armamentarium. We routinely utilize intraoperative neurophysiological monitoring (IONM) for complex brain aneurysm surgery cases, relying on direct cortical motor evoked potential (DCMEP) alerts to guide the duration of temporary clipping. Previous studies have argued for relatively short and intermittent temporary clipping strategies. In this study, we sought to assess the maximal permissive temporary clipping time during complex aneurysm surgery. To do this, we assessed patient outcome in relation to temporary clip duration guided by DCMEP. We queried our prospectively collected neuromonitoring database for anterior circulation aneurysm cases where temporary clipping was utilized by a single cerebrovascular surgeon between 2018 and 2021. Operative and IONM reports were reviewed. Patients in whom the duration of temporary clipping could not be determined were excluded. The operative strategy permissively allowed continuous temporary clipping as long as no neuromonitoring alerts were encountered. Maximal permissive parent artery occlusion time (Clipmax) was recorded as the longest duration of tolerated temporary vessel clipping without decrement in DCMEP. A total of 41 complex anterior circulation aneurysm clipping cases met criteria for this study. The mean Clipmax for all cases was just over 19min and did not differ between ruptured and unruptured aneurysms. Initial alert times were not found to be predictive of final permissive temporary clip duration after re-perfusion. In 100% (41/41) of cases, the aneurysm was completely clip occluded without residual on catheter angiogram. Stable or improved modified Rankin Score was achieved in 98% (40/41) of cases at 3-month follow-up. This study demonstrates that using DCMEP can facilitate relatively long but safe temporary clipping durations in complex anterior circulation aneurysm surgery. In the endovascular era with only a limited subset of technically challenging aneurysms needing open surgical treatment, extended permissive temporary clipping guided by DCMEPs can significantly enhance a surgeon's ability to achieve excellent technical and clinical outcomes.

Abstract WP176: Compared To Catheter Angiogram MRA Is A Moderate Predictor Of Suzuki Grade In Children With Moyamoya

Introduction: Moyamoya is a progressive cerebral arteriopathy affecting the arteries in the circle of Willis. Suzuki grade for moyamoya using catheter angiogram has been gold standard for the evaluation of moyamoya both in children and adults. Suzuki grade evaluates the amount of stenosis and collateral formation in the cerebral arteries. Magnetic resonance angiography (MRA) non-luminal imaging can overestimate stenosis and underestimate collaterals. With greater use of MRA for diagnosis and follow-up, it is important to understand MRA staging is truly comparable to catheter angiogram. Methods: Study neurologist and interventional radiologist reviewed both catheter angiograms and MRAs without clinical information. The modified Suzuki stage was used to evaluate the MRA. Median time from MRA to catheter angiogram was calculated. Cohen’s Kappa was used to compare modalities of Suzuki grade based on catheter angiogram to modified Suzuki grade by MRA on the same patients. Results: A total of 29 patients with moyamoya were reviewed. Median time between MRA and catheter angiogram was 2.4 months with interquartile range from 0.6-5.3 months. Unweighted Cohen’s Kappa was 0.34 (p<0.0001) which is considered fair correlation. When we calculated a weighted Cohen’s Kappa it improved but only to 0.49 (p<0.0001) which is moderate correlation. Conclusion: Using Cohen’s kappa to compare two methods of evaluating cerebral artery stenosis in children with moyamoya, we demonstrated that there is only moderate correlation between catheter angiogram Suzuki staging compared to modified Suzuki staging with MRA. In conclusion, we suggest caution in the reliance of MRA for diagnosis and follow-up of children with moyamoya. We recommend consideration catheter angiograms at time of diagnosis and with surgical planning.

Abstract 158: Stroke During Pregnancy: Risk Factors, Clinical Outcomes, And Recurrence

Background: There is limited data regarding the clinical course of acute stroke during pregnancy. Methods: Pregnancy-related hospitalizations with age>18 years were identified from the Nationwide Readmissions Database 2016-2018. Logistic regression and survival analyses were used to compare the risk factors, outcomes, and readmissions in patients with and without acute strokes. Results: There were 11829044 pregnancy-related hospitalizations, of which 3498 had acute stroke and a 5% random sample of the remaining non-stroke hospitalizations (N=628106) were included as controls (mean±SD age: 29.0±5.7 years). Intracranial hemorrhage (ICH) was present in 1952 (55.8%) cases, acute ischemic stroke (AIS) in 1646 (47.1%) cases, and cerebral venous sinus thrombosis in 105 (3.0%) cases. We identified several independent factors associated with acute stroke during index hospitalization (figure 1). Among patients with AIS, 60 (4.0%) received intravenous thrombolysis and 95 (6.3%) underwent mechanical thrombectomy. Among patients with ICH, 420 (23.5%) had catheter angiogram, 177 (9.9%) underwent ventriculostomy, and 14 (0.8%) underwent decompressive craniotomy. Patients with stroke had longer length of stay (mean: 11.7 vs. 2.8 days), higher in-hospital mortality (5.3% vs. 0.0001%) and were less likely to discharge home (70.3% vs. 98.4%). Non-elective readmission within 90 days of discharge occurred in 17% of patients with stroke versus in 3% without stroke [hazards ratio (HR): 5.6, 95% confidence interval (CI): 4.8-6.6]. Readmissions due to cerebrovascular events occurred in 1.8% of patients with stroke versus in 0.00004% of patients without stroke (HR: 438.6, 95% CI: 211.0-911.9) within 1 year of discharge, with mean±SD time to readmission 43.1±60.8 days. Conclusion: Stroke during pregnancy is associated with very high morbidity and mortality. Recurrence of stroke occurs in a small proportion of patients and the risk is highest during the first month.

Application of FLOW 800 in extracranial-to-intracranial bypass surgery for moyamoya disease.

The surgical treatment of moyamoya disease is heavily reliant upon a real-time understanding of cerebral hemodynamics. The application of FLOW 800 allows the surgeon to semiquantify the degree of perfusion to the cerebral cortex following extracranial-to-intracranial (EC-IC) bypass surgery. The authors present three illustrative cases demonstrating common intraoperative findings prior to and following anastomosis using FLOW 800. All patients were diagnosed by catheter angiogram with moyamoya disease and noninvasive imaging demonstrating hemispheric hypoperfusion. Superficial temporal artery (STA)–to–middle cerebral artery (MCA or M4) bypasses were performed to augment intracranial perfusion. The patients tolerated the procedures well and were discharged without event in stable neurological condition.The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21191

Arterial spin labeling as an ancillary assessment to postoperative conventional angiogram in pediatric moyamoya disease

Digital subtraction angiography (DSA) is commonly performed after pial synangiosis surgery for pediatric moyamoya disease to assess the degree of neovascularization. However, angiography is invasive, and the risk of ionizing radiation is a concern in children. In this study, the authors aimed to identify whether arterial spin labeling (ASL) can predict postoperative angiogram grading. In addition, they sought to determine whether patients who underwent ASL imaging without DSA had similar postoperative outcomes when compared with patients who received ASL imaging and postoperative DSA. The medical records of pediatric patients who underwent pial synangiosis for moyamoya disease at a quaternary children's hospital were reviewed during a 10-year period. ASL-only and ASL+DSA cohorts were analyzed. The frequency of preoperative and postoperative symptoms was analyzed within each cohort. Three neuroradiologists assigned a visual ASL grade for each patient indicating the change from the preoperative to postoperative ASL perfusion sequences. A postoperative neovascularization grade was also assigned for patients who underwent DSA. Overall, 21 hemispheres of 14 patients with ASL only and 14 hemispheres of 8 patients with ASL+DSA were analyzed. The groups had similar rates of MRI evidence of acute or chronic stroke preoperatively (61.9% in the ASL-only group and 64.3% in the ASL+DSA group). In the entire cohort, transient ischemic attack (TIA) (p = 0.027), TIA composite (TIA or unexplained neurological symptoms; p = 0.0006), chronic headaches (p = 0.035), aphasia (p = 0.019), and weakness (p = 0.001) all had decreased frequency after intervention. The authors found a positive association between revascularization observed on DSA and the visual ASL grading (p = 0.048). The visual ASL grades in patients with an angiogram indicating robust neovascularization demonstrated improved perfusion when compared with the ASL grades of patients with a poor neovascularization. Noninvasive ASL perfusion imaging had an association with postoperative DSA neoangiogenesis following pial synangiosis surgery in children. There were no significant postoperative stroke differences between the ASL-only and ASL+DSA cohorts. Both cohorts demonstrated significant improvement in preoperative symptoms after surgery. Further study in larger cohorts is necessary to determine whether the results of this study are validated in order to circumvent the invasive catheter angiogram.

A Rare Combination of Vascular Complications from Recurrent Pancreatitis Challenging the Treatment

A 43-year-old male alcoholic with recurrent acute pancreatitis presented with periodic melena. Computed tomography showed a 4.2 cm pseudoaneurysm encroaching on the head of pancreas and cavernous transformation of portal vein (portal cavernoma) caused by chronically thrombosed splenomesenteric portal axis (Figure A and B). The catheter angiogram revealed the pseudoaneurysm arising from a branch of replaced right hepatic artery from superior mesenteric artery (Figure C). Superselective embolization to occlude the feeding branch was performed using embolization coils, but misplacement of a coil resulted in complete occlusion of the right hepatic artery (Figure D.) However, the post- procedural liver function test remained within normal limits.

Determination of Sensitivity and Specificity of High Resolution CT Scan in Evaluation of Cardiac and Extra-Cardiac Anomalies among Bangladeshi Children

Congenital heart disease (CHD) is one of the important causes of morbidity and mortality in the pediatric age group. Invasive angiography is considered as gold standard method for the diagnosis of pediatric cardiovascular diseases. Multi-detector CT cardiac angiogram by using 64 slice scanner is a useful modality and suitable alternative to previous invasive procedure in evaluation of congenital heart disease. The present study was conducted in the Department of Cardiology of NICVD during the period of September 2019 to August 2020 (One year). We selected 40 patients presenting in the outpatient department of National Institute of Cardiovascular Diseases and Hospital (NICVD) who were diagnosed to have congenital heart disease clinically and radiologically. CT angiogram revealed ASD in 10%, coarctation of aorta in 5%, Pentalogy of Fallot in 2.5%, Tetralogy of Fallot (TOF) in 32.5%, Ventricular septal defect (VSD) in 30.0%, PAH in 2.5%, PS in 5%, RVH with PS in 2.5%, PDA in 5% and Tricuspid atresia with ASD with VSD with PS in 2.5% patients. Conventional catheter angiogram revealed ASD in 5%, VSD in 32.5%, TOF in 30%, PS in 12.5%, Coarctation of aorta in 5% and Pentalogy of Fallots in 5%. The diagnostic performance of MDCT in the diagnosis and evaluation of congenital heart disease was high.

"Craniotomy Within Craniotomy" Technique for Safe Resection of an Intracranial Arteriovenous Malformation With Frontal Bony Erosion: 2-Dimensional Operative Video.

Surgical resection is one option in the treatment of large high-grade brain arteriovenous malformations (AVMs). Resection of AVMs with skull-eroding components can be challenging due to the risk of excessive bleeding from these components during craniotomy and bone flap removal. We present a case of a 25-yr-old woman who presented with an acute onset right-sided frontal headache. She was found to have a large, frontal Spetzler-Martin grade IV AVM with an associated dural AVM. The AVM had caused focal erosions of the right frontal bone by a venous varix traversing the region of the calvarial defect. An elective staged endovascular embolization followed by surgical resection was recommended considering the patient's young age and the large size of the AVM located in a noneloquent area. Given the high risk of intraoperative hemorrhage during the craniotomy portion of the procedure, a "craniotomy within craniotomy" approach was planned. During this approach, a small rectangle of bone, including the portion eroded by the venous varix, was left in place, while the larger bone flap surrounding it was removed for an initial approach to the AVM. The small bony piece was safely removed at later stages of resection once the arterial feeders had been reasonably obliterated. Immediate postoperative catheter angiogram demonstrated good filling of the intracranial vascular territories with no residual AVM. The patient developed mild left facial and left hand weakness postoperatively, which resolved after 2 wk of follow-up. The patient remained neurologically intact on further follow-up.

Abstract 1122‐000005: Plasminogen Activator Inhibitor‐1 5G/5G Polymorphism – Do We Know All About It?

Introduction : The etiology of ischemic stroke is heterogeneous, and it has been proposed that different stroke subtypes might have different genetic architecture 1,2. The plasminogen activator inhibitor‐1 (PAI‐1) has been of particular interest due to its role in thrombotic diseases. Several polymorphisms have been found for this gene, with some having protective effect while others increase the risk of ischemic and hemorrhagic strokes 3,4. The protective role appears to be due to the role of PAI‐1 in fibrinolytic cascade and that PAI‐1 also inhibit plasmin‐dependent metalloproteinases activation. We hereby, present a case of ischemic stroke in young adult and its association with our gene of interest. Methods : Case: We present a case of 43‐year‐old woman with past medical history significant for Acetylcholine Receptor (AChR) antibody positive Myasthenia Gravis diagnosed in 1993 status post thymectomy (1994), currently on prednisone and intravenous immunoglobulin every two weeks (failed cyclosporine and mycophenolate mofetil). She had two events in 2018 where she reported episodic right sided numbness and weakness that lasted for few hours. Stroke workup was done, and she was found to have focal moderate to severe stenosis of the left middle cerebral artery (MCA) on CT angiography (figure 1) with very subtle left hypoperfusion in the MCA on the brain single‐photon emission computerized tomography scan. She underwent catheter angiogram (figure 1) showing severe stenosis involving the mid and distal M1 segment of the left MCA and nondominant proximal A1 segment left anterior cerebral artery (ACA). There were robust leptomeningeal collaterals from the left anterior and left posterior cerebral arteries. She also reported history of two miscarriages in the first trimester. Hypercoagulable workup was done and all of those were negative including: SLE profile, Lupus anticoagulant, ANA comprehensive panel, Cryoglobulin, Anticardiolipin antibody, Antithrombin III, Antithrombin antigen, protein C, protein S, Factor VIII activity, Factor V Leiden. She also had rheumatoid arthritis factor, Homocysteine, sedimentation rate, and C‐reactive protein done which were unremarkable. Genetic workup showed that she is PAI‐1 5G/5G homozygous. She has been stable since 2018 without new focal neurological events and is on Aspirin monotherapy and Statin. Results : The genetics for stroke disease are very complicated and yet to be discovered fully. The association between PA‐1 5G/5G and intracranial stenosis has not been reported previously. New genetic associations will need to be increasingly considered as we assess our cerebrovascular diseases and stroke patients Conclusions : • With the current knowledge, ischemic stroke have polygenic basis but no single common “stroke gene” has been identified yet. • Here we present a case suggesting that PAI‐1 5G/5G genotype is may be associated with an independent risk of intracranial atherosclerosis.

Superior sagittal sinus dural arteriovenous fistula caused by treatment of meningioma masquerades as sinus thrombosis

Dural arteriovenous fistulas (DAVF) are rare acquired lesions resulting from abnormal shunting between intracranial dural arteries and venous system. Typically arising from structural weakness of the dura and a coinciding trigger factor, DAVFs can present with similar clinical and imaging characteristics to sinus thrombosis. A 61-year-old male with a history of meningioma previously managed with subtotal resection and stereotactic radiosurgery presented with progressive right-sided vision loss and bilateral papilledema. Initial imaging suggested possible sinus occlusion. Catheter angiogram revealed a Borden-Shucart grade III DAVF of the superior sagittal sinus and elevated venous pressures and the patient subsequently underwent endovascular transarterial intervention twice. We report on the first case of a superior sagittal sinus DAVF occurring after surgical resection of a parasagittal meningioma.

Challenges in Diagnosis and Management of Previously Embolized Spinal Dural Arteriovenous Fistulae

Given the growing prevalence of initial endovascular treatment for type 1 spinal dural arteriovenous fistulae (dAVF), there are an increasing number of patients presenting with progressive symptoms related to recurrent previously embolized spinal dAVF. This study's goal was to identify demographic, clinical, and radiographic variables among patients who have failed embolization of type I spinal dAVF. A retrospective review of 24 consecutive surgeries for type I spinal dAVF performed by the senior author (A.D.L.) identified 5 patients who underwent open surgery for failed embolization. These 5 cases were reviewed for location of fistula, time from embolization to recurrence, preoperative functional status, fistulous point encountered at surgery, and clinical outcome of the patient at 3-month follow-up. A representative example case is reviewed in detail. The median age at time of recurrence was 63 years (range 51-73 years). The median timing of embolization to recurrence of neurologic symptoms was 5 months (range 1-54) and to surgery 7 months (range 2-60 months). The level of the spinal dAVF was most frequently at T12-L1 (n= 3). Spinal magnetic resonance arteriography led to localization of the spinal dAVF in 2 patients and spinal catheter angiogram in 3 cases. All patients had definitive radiographic cure of the dAVF at last clinical follow-up. The increased use of endovascular treatment of spinal dAVF has led to the treatment of refractory cases with a greater degree of surgical complexity. Open surgical ligation continues to provide the most definitive treatment outcomes for this complex spinal vascular entity.

Rescue Thrombectomy for Early Hepatic Artery Thrombosis Using Stent Retriever in a Child Post Combined Deceased Donor Liver and Renal Transplant

AbstractWe report this case of a 5-year-old child post combined liver and renal transplant for primary hyperoxaluria. Patient developed hepatic artery thrombosis on day 3 posttransplant that was managed by reexploration and reanastomosis of the hepatic artery. On day 4, the patient again developed hepatic artery thrombosis that failed to revascularize by surgical exploration and reanastomosis. Tissue plasminogen activator was injected into the hepatic artery intraoperatively to lyse any clot; however, no revascularization could be achieved. Subsequently, catheter angiogram confirmed no flow in the hepatic artery. A4 × 22 mm revive stent retriever was deployed across the site of occlusion and retrieved after 5 minutes of indwell time. Two such passes were made and complete recanalization of the hepatic artery was achieved. The hepatic artery remained patent as confirmed on serial Doppler images post intervention.

Abstract No. 64 Analysis of complications and unsuccessful embolization of pulmonary arteriovenous malformations

Embolotherapy is the standard treatment for pulmonary arteriovenous malformation (pAVM). The purpose of this study is to explore the reasons for unsuccessful embolization and complications associated with embolotherapy. This retrospective chart review study was approved by the IRB. Data were collected for all the embolization procedures that were performed at our institution for pulmonary AVM treatment between January 2003 and January 2020. All ages of both genders were included in the analysis. The reason for unsuccessful embolization and complications were recorded. One hundred and eighty-seven patients had a total of 341 embolization procedures at our institutions for the treatment of PAVM. There were 240 (70%) women and 101 (30%) men included with a mean age of 49 ± 18 and 38 ± 20 years, respectively. The average fluoroscopic time was 34 minutes (range 3.4 to 120 minutes). Of 341, 47(14%) procedures were unsuccessful. The reason for unsuccessful embolization were (in order of frequency): no PAVM detected on catheter angiogram (n = 17, 36%), pAVM too small to treat (n = 12, 25%), tortuous feeding artery causing technical difficulty assessing the artery (n = 7, 15%), No evidence of reperfusion on follow up pulmonary angiogram (that were done to detect reperfusion) (n = 6, 13%), systemic arterial supply to the pAVM causing vein to vein shunting (n = 3, 6%), patient’s condition (increased respiratory motion and intraprocedural bradycardia) aborting the procedure (n = 2, 4%). There were a total of 9 (2%) intraprocedural complications with 2 major complications aborting the embolotherapy. Embolization of pulmonary arteriovenous malformation is a very successful procedure with minor complications. The main reasons of unsuccessful embolotherapy are no evidence of pAVM during catheter angiogram, very small feeding artery size, and tortuous feeding artery.

Abstract No. 218 Diagnostic accuracy of computed tomography angiogram chest in detecting pulmonary arteriovenous malformation: a comparison with invasive catheter pulmonary angiogram

To determine the diagnostic accuracy of computed tomography angiography (CTA) of the chest in the detection of pulmonary arteriovenous malformations (pAVM) compared to invasive pulmonary catheter angiogram of the chest both in HHT and non HHT patients. This retrospective study was approved by the institutional review board. A total of 341 pulmonary angiograms were performed for either embolization (treatment) of pAVM or for diagnosis of pAVM at our institution from January 2003 to June 2020. Two angiograms were excluded as they did not have prior CTA for pAVM. The remaining 339 pulmonary angiograms had an immediate prior CTA of the chest within a mean 7 ± 30 (SD) days prior to pulmonary angiogram. CTA was acquired after intravenous administration of contrast. The kV and mA were selected based on patient weight and ranges between 80 to 140. The mean fluoroscopy time was 33 ± 19 SD with range 2.4 to 120 minutes. Positive CTA of the chest was defined as the presence of pulmonary arteriovenous malformation with at least one well-defined feeding artery and a draining vein. A 2 × 2 contingency table was constructed and sensitivity, specificity, PPV, NPV, and accuracy were calculated. One hundred and eighty-five patients were included with mean age of 46 ± 19 SD, range 3 to 87 years with 68% of female. A total of 337 CTA of the chest were positive and 319 catheter pulmonary angiograms were positive for pulmonary AVM. There were 318 true positive, 19 false positives, 1 true negative, and 1 false negative. CTA angiogram chest demonstrated a sensitivity of 99.7%, a specificity of 5.0%, a positive predictive value of 94.4%, and a negative predictive value of 50.0%. Overall, the diagnostic accuracy of CTA angiogram chest was 94.10%. False positive CTA causes were catheter angiogram did not detect micro shunt (6/339), pulmonary vein to vein shunt (5/339), CTA wrong call for reperfusion (3/339), calcified granuloma (2/339), and tortuous or dilated pulmonary vessel (2/339). In the false negative CTA was not able to detect micro shunt (1/339). The limitation of our study is low specificity as those patients that have negative CTA angiogram chest do not proceed for catheter pulmonary angiogram unless they have other comorbidities and require CTA of the chest. Our result demonstrates that CTA of the chest is highly sensitive in detecting pulmonary arteriovenous malformation. This again highlights the importance of screening of pulmonary AVM in HHT patients.

Abstract No. 558 Does lung shunt fraction estimation using injection of 99mTc-MAA still vital in 90Y radioembolization dosimetry? A hypothetical study using patient specific information

To compare and estimate the impact of actual vs. arbitrarily chosen lung shunt fraction (LSF) on 90Y radioembolization dosimetry Institutional review board approved this retrospective study of patients who underwent invasive catheter angiogram with injection of macroaggregated albumin (99mTc-MAA) to measure the actual LSF that was then used in 90Y dosimetry for glass microspheres based radioembolization for hepatocellular carcinoma in 2017 and 2018. 40 patients (mean age, 68 years) underwent 44 injections of 99mTc-MAA. Details related to the targeted liver volume, 99mTc-MAA and 90Y procedures were collected from medical records. Impact of arbitrarily chosen LSF on 90Y dosimetry was compared with the 90Y dosimetry based on actual LSF. There was on average 22 days (range, 10–44) delay between the 99mTc-MAA and 90Y procedures. The mean actual LSF was 4.9% (range, 0.8%–11.3%). Average mass of the treated liver was 0.791 kg (range, 0.3–2.36). The mean prescribed radiation dose was 153.7 Gy (range, 110– 320 Gy). The actual radiation dose deposited by glass microspheres was estimated to be 153.4 Gy (range, 100.6–318.4). Alternatively, if 90Y dosimetry is calculated using an arbitrarily chosen LSF of 5%, a minimum commercially available radioactivity (i.e., 3 GBq at the time of calibration) required for the smallest treatment mass (0.3 kg) in this study group would deposit a dose of 118 Gy at 4 pm on a Friday, and the maximum commercially available radioactivity (20 GBq) for the largest treatment mass (2.36 kg) would deposit a dose of 321 Gy at 8 am on a Monday. This study indicates the feasibility of using arbitrary LSF in 90Y dosimetry. When a range of commercially available vials of radioactivity is readily available at the treatment enter, glass microspheres based radioembolization using arbitrarily chosen LSF based 90Y dosimetry would be feasible without the need for 99mTc-MAA injection in most patients. However, an alternative method to predict and identify the small percentage of patients who could have high LSF is required to prevent significant pulmonary injury from radioembolization based on arbitrarily chosen low LSF.

External Carotid Artery-to-Middle Cerebral Artery Bypass Using a Saphenous Vein Graft With 3-Vessel Anastomosis for the Treatment of a Large, Ruptured Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video.

Cerebral revascularization is the treatment of choice for select complex intracranial aneurysms unamenable to traditional approaches.1 Complex middle cerebral artery (MCA) bifurcation aneurysms can include the origins of 1 or both M2 branches and may benefit from a revascularization strategy.2,3 A novel 3-vessel anastomosis technique combining side-to-side and end-to-side anastomoses, allowing for bihemispheric anterior cerebral artery revascularization, was recently reported.4 This 2-dimensional operative video presents the case of a 73-yr-old woman who presented as a Hunt-Hess grade 4 subarachnoid hemorrhage due to the rupture of a large right MCA bifurcation aneurysm. The aneurysm incorporated the origins of the frontal and temporal M2 branches and was deemed unfavorable for endovascular treatment. A strategy using a high-flow bypass from the external carotid artery to the MCA with a saphenous vein (SV) graft was planned to revascularize both M2 branches simultaneously, followed by clip-trapping of the aneurysm. Intraoperatively, the back walls of both M2 segments distal to the aneurysm were connected with a standard running suture, and the SV graft was then attached to the side-to-side construct in an end-to-side fashion. Catheter angiograms on postoperative days 1 and 6 demonstrated sustained patency of the anastomosis and good filling through the bypass. The patient's clinical course was complicated by vasospasm-related right MCA territory strokes, resulting in left-sided weakness, which significantly improved upon 3-mo follow-up with no new ischemia. The patient consented for inclusion in a prospective Institutional Review Board (IRB)-approved database from which this IRB-approved retrospective report was created.

Endovascular treatment of visceral aneurysms and pseudoaneurysms.

Visceral artery aneurysm (VAA) is a rare and potentially life-threatening condition, defined as true artery aneurysms and pseudoaneurysms of splanchnic circulation and renal artery. This study reports our experience in the diagnosis and endovascular treatment of visceral artery aneurysms (VAAs) over a 10-year period. Between 2008 and 2018, a total of 24 VAAs in 21 patients were diagnosed by clinical symptoms and a combination of imaging techniques, such as Doppler ultrasound, computed tomography angiogram, and catheter angiogram. All patients underwent endovascular treatment to exclude aneurysms. Oral antiplatelet medicine was administered, and imaging examination was performed during follow-up. Technical success was achieved in all 21 patients, and no periprocedural complications occurred. Endovascular coiling alone was employed in 10 aneurysms. Coiling was combined with gelfoam in 2 aneurysms. Coiling was assisted by stent in 4 aneurysms. Covered stents were deployed in 8 aneurysms individually. Clinical symptoms disappeared or highly improved in all patients after treatment. None of the patients showed recurrent symptoms after discharge. However, two cases with new aneurysms after 6 and 8 months, respectively, and one case with in-stent thrombosis after 12 months were reported during follow-up. This study may justify the efficacy of percutaneous endovascular coil embolization and stent deployment. It also provides beneficial experience about how to choose appropriate various endovascular strategies based on both clinical symptoms and aneurysm anatomy condition.

Anomalous Celiac Trunk Variation Encountered in Y-90 Radioembolization

Background: 
 Yttrium-90 microsphere embolization is a selective internal radiation therapy (SIRT) used in the treatment of hepatocellular carcinoma and liver metastases. Current literature recommends lobar, or more selective, infusion of SIRT to allow for precise radiation administration and to mitigate risk of non-target embolization. Lobar infusion requires knowledge of anatomical variations of hepatic arterial supply. The trifurcation of the celiac trunk into the left gastric artery, splenic artery, and common hepatic artery is the most common presentation representing 51% to 89% of patient anatomy. A replaced right hepatic artery (RHA) arising from the superior mesenteric artery (SMA) is one of the most common variants of hepatic arterial supply with a prevalence of 10.6% to 15%. Common variations such as these are well described and easily mapped using catheter angiography, but rarer variations are not as well described and more challenging to map. 
 
 Project Methods: 
 Mapping catheter angiogram of the celiac trunk and SMA was obtained. Additional aortogram and CT angiogram were obtained to further elucidate patient’s anatomy. 
 
 Results: 
 Initial mapping angiogram was only partially successful because the RHA could not be selected. Abdominal aortogram and CT angiogram of the abdomen and pelvis revealed a replaced RHA arising directly from the distal celiac trunk. Additionally, the patient had a replaced cystic artery arising from the left hepatic artery and an arc of Buhler connecting the proximal SMA to the proximal aspect of the right hepatic artery. 
 
 Conclusion: 
 Radiologists need to be aware of rare variations in hepatic arterial supply for the safe and effective treatment of hepatic neoplasms, whether primary or metastatic. Description of arterial variation and informed selection of arterial branches will remain a critical aspect of improving efficiency and reducing risks of hepatic embolization procedures.

Simple Provisional Stenting or two-stent Strategies to Treat Anomalous Right Coronary Originating from the mid of left Anterior Descending Coronary Artery

Congenital anomalies of coronary arteries (CAAS) are very rare and usually documented as an incidental finding during routine catheter or CT angiograms performed for other reasons. Their prevalence ranges from 0.2% to 1.3% based published series. The most common coronary artery anomaly is origination of the left circumflex coronary (LCX) artery from the proximal of right coronary artery (RCA) or right sinus of Valsalva. The second is separate origination of the left anterior descending coronary artery (LAD) and LCX artery from the left sinus of Valsalva. Herein, we present three cases that the anomalous RCA arises from the mid of left anterior descending coronary artery (LAD). The bifurcation lesions of first case was treated using two-stent strategies of DK culotte, excellent angiography results was observed. The last two cases were treated using simple provisional stenting strategy: one stent was deployed crossover the ostium of the anomalous coronary artery, final angiographic results were excellent. These cases are extremely rare. We bring forth them in an attempt to highlight their significance, and make cardiologist to understand what important the anomalies are, and the strategy how to treatment these bifurcation lesions.

A Novel Parameter to Predict Supraclinoid Aneurysm Persistence After Flow Diversion with the Pipeline Embolization Device

Aneurysm recurrence after Pipeline Embolization Device (PED) placement can be caused by oversizing of the stent as well as poor wall apposition, both of which can lead to elongation. The objective of this study was to assess whether a novel parameter for measuring device elongation based on two-dimensional imaging could be predictive for persistent aneurysm filling after treatment with the PED. A retrospective cohort analysis was initially completed on 41 aneurysms from institution A, examining demographic, aneurysmal, and device measurements. Device measurements, including the ratio of the measured length to the nominal length (ML/NL) of the PED, were taken by reviewers blinded to the primary end point, which was aneurysm occlusion status on 6 month catheter angiogram. Findings were then externally validated against 30 aneurysms (supraclinoid only) from institution B. Data from institution A showed 61% complete aneurysm occlusion at 6 months, and were lower for aneurysms in the supraclinoid region. For supraclinoid aneurysms alone, combined data from both institutions showed higher rates of nonocclusion with aneurysm neck size >4 mm (P= 0.008) and a trend toward significance in aneurysms with a branch vessel (P= 0.051). The mean ML/NL ratio was significantly larger in the nonoccluded group compared with the occluded group at both institution A (ratio, 1.37 versus 1.10; P < 0.001) and institution B (ratio, 1.36 vs. 1.11; P= 0.002). Our data suggest that a novel parameter based on two-dimensional angiography may serve as a rapid technique to measure device elongation and predict occlusion of supraclinoid aneurysms after PED placement.