Standard femoral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) severely limits patient mobility. We introduce a novel "femoral-free" Ambulatory Subclavian-Jugular V-A ECMO technique to maximize rehabilitation capabilities. We employed a subclavian-right internal jugular configuration. Initially, a vascular graft anastomosis was used for arterial return, but this resulted in upper limb swelling. Subsequently, we modified our approach as a technical refinement: inserting a 17-Fr reinfusion cannula directly into the right subclavian artery with a 6-Fr distal perfusion catheter to prevent arm ischemia. For drainage, a long venous cannula was inserted into the right internal jugular vein and advanced to the inferior vena cava. Furthermore, inserting the drainage cannula via the internal jugular vein in a retrograde fashion, contrary to the conventional approach, provided adequate venous drainage for ECMO support. This optimized configuration maintained stable ECMO flow (3.5-4.0L/min) and enabled active bedside rehabilitation comparable to that of dual-lumen veno-venous ECMO. Notably, no right arm swelling was observed with the direct cannulation method in our single case, although this observation requires further validation. This "femoral-free" approach is a feasible and effective strategy for patients requiring prolonged V-A ECMO support, such as bridge-to-transplant candidates, by facilitating continuous active physical therapy. Direct cannulation may represent a promising technical refinement to minimize local limb complications, though comparative conclusions cannot be drawn from this limited experience.

Ventriculoperitoneal shunt surgery (VPS) remains a mainstay for the treatment of hydrocephalus. This study compared the short-term efficacy and perioperative safety of a neuroendoscopic-assisted abdominal wall puncture technique for distal catheter placement with laparoscopy-assisted open laparotomy. We conducted a single-center, non-randomized, time-sequence controlled cohort study. Patients who underwent VPS with distal catheter placement via laparoscopy-assisted open laparotomy between January 2020 and December 2021 were assigned to the Open Laparotomy Group (OLG), whereas those treated using the neuroendoscopic-assisted abdominal wall puncture approach between January 2022 and April 2025 were assigned to the Abdominal Wall Puncture Group (APG). Perioperative inflammatory markers, operative parameters, and early radiological and functional outcomes were compared between groups. Intraoperative technical difficulties, peritoneal adhesions, and complications were descriptively recorded. Safety of CO₂ pneumoperitoneum was monitored by postoperative head CT. not applicable. Sixty-nine patients were included (APG, n = 34; OLG, n = 35). On postoperative day 1 and day 3, white blood cell and neutrophil counts were significantly lower in the APG than in the OLG (all p < 0.05). The Evans index and Activities of Daily Living (ADL) scores were comparable between groups preoperatively and at 3 days postoperatively (all p > 0.05), while both measures improved from baseline within each group (all p < 0.05). Compared with the OLG, the APG was associated with reduced intraoperative blood loss (p = 0.023), shorter operative time (p = 0.040), and shorter postoperative length of stay (p = 0.016). No intraoperative visceral injury or catheter malposition requiring revision occurred in either group. Peritoneal adhesions were observed in 3 OLG patients and 2 APG patients, none requiring conversion. In the APG, postoperative head CT on day 1 showed no intraventricular or subdural air. The incidence of distal shunt obstruction within 3 months was low and did not differ significantly between groups (p = 0.115). In this non-randomized, time-sequence cohort, neuroendoscopic-assisted abdominal wall puncture for distal catheter placement was associated with less perioperative blood loss, lower early postoperative inflammatory markers, and shorter operative time and hospital stay, while achieving similar early radiological and functional improvement and short-term shunt patency compared with laparoscopy-assisted open laparotomy. However, given the limited sample size, the non-randomized design, and the short (3-month) follow-up, these results support only preliminary conclusions. Longer-term follow-up (e.g., ≥ 1-2 years) is required to evaluate late complications and shunt durability, including distal obstruction, catheter migration, peritoneal adhesions, and infection.

Real-time three-dimensional robotic C-arm navigation for ventriculoperitoneal shunt placement: a single-center retrospective study.

Vein Enlargement Induced by Normal Saline (VEINS) technique: A prospective evaluation of a novel approach to venodilation.

Modifying a traditional femoral venoarterial extracorporeal membrane oxygenation cannulation strategy and circuit to improve distal limb hemodynamics.

Retrograde perfusion of the dorsalis pedis artery versus traditional distal perfusion catheter use in venoarterial extracorporeal membrane oxygenation.

The first-pass effect (complete or near-complete reperfusion [extended TICI 2b-3] after a single thrombectomy pass) is a key functional outcome determinant. This study identified factors associated with first-pass effect and quantitatively evaluated how balloon-guided catheter positioning relates to first-pass effect achievement during anterior circulation mechanical thrombectomy. We retrospectively analyzed a prospectively maintained database of consecutive patients with anterior circulation large-vessel occlusion who underwent mechanical thrombectomy using a balloon-guided catheter between May 2022 and February 2025. The balloon-guided catheter tip to the proximal petrous ICA distance was measured using lateral angiography at the initial balloon-guided catheter position. Factors associated with first-pass effect were evaluated using univariate and multivariate logistic regression analyses. Receiver operating characteristic curve analysis determined the optimal cutoff value for predicting first-pass effect. Among 110 patients (median age, 81 years; 54% men), 56% achieved first-pass effect. A shorter balloon-guided catheter tip to proximal petrous ICA distance was independently associated with higher first-pass effect rates (adjusted OR, 0.96; 95% CI, 0.94-0.98; P < .001). Greater distance correlated with longer procedure time (r = 0.3; P < .001) and more thrombectomy passes (P < .001). Receiver operating characteristic analysis identified 24 mm as the optimal cutoff (area under the curve, 0.7). Distal balloon-guided catheter positioning was associated with fewer distal emboli and shorter recanalization time without serious complications. Distal balloon-guided catheter placement within 24 mm of the proximal petrous ICA independently predicted higher first-pass effect achievement and greater procedural efficiency. Quantitative balloon-guided catheter position assessment may provide a practical intraoperative metric to optimize mechanical thrombectomy strategies.

Periprocedural thromboembolic events are common complications of neuroendovascular treatment. We aimed to determine the incidence and potential risk factors of DWI-positive lesions detected on postoperative MRI after Woven EndoBridge (MicroVention/Terumo, Aliso Viejo, CA, USA) treatment for intracranial aneurysms. Between February 2021 and April 2025, 55 patients underwent Woven EndoBridge treatment for 59 intracranial aneurysms at two neurovascular institutions in Japan. Of these, 37 patients with 40 unruptured intracranial aneurysms treated with the Woven EndoBridge device alone were retrospectively enrolled. The distal access catheter/parent artery ratio was defined as the outer diameter of the distal tip of the distal access catheter divided by the diameter of the parent artery. MRI was performed within 48 hours after the procedure to evaluate appearance and number of DWI-positive lesions. DWI-positive lesions after Woven EndoBridge treatment were confirmed in 28 (70.0%) unruptured intracranial aneurysms. Univariate analysis revealed a trend toward a higher proportion of age ≥70 years (DWI-positive lesion [-] group: 33.3% vs [+] group: 64.3%, P=.09). The proportion of distal access catheter/parent artery ratio ≥0.70 differed significantly between the two groups (DWI-positive lesion [-] group: 8.3% vs [+] group: 53.6%, P=.01). In the multiple logistic regression model using age and distal access catheter/parent artery ratio, a distal access catheter/parent artery ratio (OR, 111.00; 95% CI, 0.76-16000.00; P=.06) was identified as a marginally significant risk factor for postprocedural DWI-positive lesions. Furthermore, the eligible cases were divided into two groups: DWI-positive lesion ≥10 (-) group (n=31, 77.5%) and ≥10 (+) group (n=9, 22.5%). Univariate analysis revealed significant differences in the proportion of age ≥70 years (45.2% vs 88.9%, P=.03) and those with a distal access catheter/parent artery ratio ≥0.80 (9.7% vs 66.7%, P=.001). In the multiple logistic regression model using age and distal access catheter/parent artery ratio, a significant relationship was found between distal access catheter/parent artery ratio (OR, 1400.00; 95% CI, 3.70-533000.00; P=.02) and postprocedural DWI-positive lesion ≥10 following Woven EndoBridge treatment. Distal access catheter/parent artery ratio in Woven EndoBridge treatment may affect DWI-positive lesions incidence and postprocedural count.

Background: Lower extremity ischemic complications of peripheral veno-arterial (VA) ECMO are common and variably reported across studies due to differences in definitions and distal perfusion practices, and are influenced in part by arterial cannula size.1,2 Typical arterial return cannula sizes used for adult ECPR are 17Fr or 15Fr.3. Purpose: We hypothesized that reducing arterial cannula size from 15Fr to 13Fr may reduce the need for distal perfusion catheter (DPC) placement for suspected cannula-associated threatened limb ischemia while maintaining adequate flows to support patients requiring ECPR. Research Design and Study Sample: We conducted a retrospective cohort analysis evaluating 39 adult ECPR patients at our center, comparing outcomes between those receiving 13Fr (n = 18) versus 15Fr (n = 21) arterial cannulas (Medtronic Bio-Medicus). Analysis: The primary endpoint was the rate of DPC placement for suspected cannula-associated limb ischemia. Secondary endpoints included ECMO flow parameters, illness severity markers, support duration, and 30-days survival. Results: The rate of DPC placement was significantly lower in the 13Fr group (16.7%) compared to the 15Fr group (47.6%, p = 0.04). There were no significant differences observed in survival rates, illness severity markers, or support duration between cohorts. Conclusions: These findings support the feasibility of smaller arterial cannulas as a strategy to reduce the need for additional limb reperfusion procedures in select ECPR patients.

Abstract Introduction Embolization via the transvenous route is an established treatment for cavernous sinus (CS) dural arteriovenous fistula (DAVF). Among transvenous approaches, the trans-middle temporal vein (MTV)-superior ophthalmic vein (OphV) route is less commonly employed but represents a viable alternative. However, associated superior OphV stenosis can result in postoperative periorbital swelling secondary to impaired venous drainage. A rare case of this complication is reported. Case presentation A 71-year-old woman presented with a two-month history of swelling and redness in the right eye. One month earlier, she had undergone an unsuccessful transvenous embolization through the inferior petrosal sinus. On examination, swelling of the upper eyelid and conjunctival congestion were noted in the right eye. Under general anesthesia, angiography revealed a CS DAVF with MTV drainage. The trans-MTV-OphV procedure was subsequently performed. A 6 F supporting catheter was placed in the right brachiocephalic vein, followed by successful advancement of a 4.6 F distal access catheter into the MTV. The arterial roadmap demonstrated a stenotic superior OphV. A microcatheter was then navigated through the stenotic OphV and advanced to the origin of the OphV, where coiling and Onyx casting achieved complete obliteration of the DAVF. Postoperatively, the patient developed periorbital swelling secondary to stenosis and impairment of the OphV. Prednisolone (500 mg once daily) was administered for three days, leading to the resolution of the periorbital swelling. Conclusion In cases of CS DAVF, the trans-MTV-superior OphV approach may represent a viable venous access alternative. However, superior OphV stenosis can result in postoperative periorbital swelling, resulting in impaired venous drainage. Glucocorticoid therapy may be effective in managing this complication.

A bstract Ventriculoperitoneal shunt surgery is the primary treatment for hydrocephalus; however, while common complications include infection and dysfunction, shunt-related acute abdomen syndrome due to catheter knotting is exceedingly rare, with fewer than 30 cases reported in the literature. We present a 9-year-old male with congenital hydrocephalus and a history of neonatal surgery for esophageal atresia and Nissen fundoplication who, despite having a stable neurological course for 8 years, suffered from multiple hospitalizations due to nonspecific gastrointestinal symptoms. He eventually presented with acute nausea, vomiting, and abdominal distension, where radiography revealed distal shunt knotting and acute ileus. Emergency laparotomy confirmed a small bowel volvulus caused by the knotted catheter, and following externalization, the patient was successfully treated with a ventriculoatrial shunt. Based on our clinical observations and literature review, we identified that knotting occurs at intestinal “corner points” where chronic peristaltic movements force redundant catheter lengths to rotate and eventually self-entangle. To overcome the limitations of 2D imaging and improve diagnostic accuracy, we emphasize the potential of developing three-dimensional computed tomography reconstruction techniques, similar to those used in aneurysm surgery, to better visualize the spatial orientation of the catheter. We conclude that managing distal catheter length and maintaining a high clinical suspicion regarding the “neurologically silent phase” are the cornerstones of preventing such life-threatening complications, particularly in patients with complex abdominal histories.

Mechanical thrombectomy is the standard of care for acute ischemic stroke due to large vessel occlusion, but the optimal combination of devices remains under investigation. The SEMTiC-01 trial evaluates the safety and efficacy of a novel, fully integrated neurothrombectomy system composed of the iNedit balloon distal access catheter, the iNdeep microcatheter, and the iNtercept stent retriever. SEMTiC-01 is a prospective, multicenter, single-arm, open-label trial conducted across 18 centers in Spain, Germany, and Belgium. A total of 175 patients with LVO stroke were enrolled and treated within 24h of symptom onset. The primary efficacy endpoint was the rate of successful reperfusion (eTICI ≥2b) in ≤3 passes. The primary safety endpoints included serious adverse events within 24h and 90-day mortality. Secondary endpoints included good functional outcome (mRS 0-2 at 90 days), early neurological improvement, and device navigability. Successful reperfusion was achieved in 75.4% of the intention-to-treat (ITT) and 83.6% of the per-protocol (PP) population. Good functional outcomes were observed in 55.8% (ITT) and 56.9% (PP), and rapid neurological improvement in 64.6% of patients. First-pass reperfusion (eTICI ≥2b) was obtained in 46.9% (ITT) and 51.4% (PP). Symptomatic intracranial hemorrhage occurred in 1.7% (ITT), and mortality at 90 days was 13.7%. Device navigability was rated "Good" in over 75% of cases for both iNedit, iNtercept and iNdeep. Balloon inflation during thrombectomy improved outcomes in M1 occlusions. The triad system (iNedit, iNdeep and iNtercept) demonstrates non-inferiority compared published literature, with favorable safety and efficacy profiles. Its favourable navigability suggests it is a promising option for mechanical thrombectomy in acute ischemic stroke.

Background: hydrocephalus is a common condition in neurosurgical practice. Although the placement of a ventriculoperitoneal shunt (VPS) has significantly improved patient outcomes, the procedure is not without complications. Among these, subcutaneous retrograde migration of the distal catheter is a rare event, with few cases reported in the literature. Objectives: to present a series of cases of subcutaneous retrograde migration of the distal catheter in ventriculoperitoneal shunt systems, describe their clinical and imaging characteristics, and propose a surgical strategy for their management. Case description: we present five patients with suspected valvular dysfunction due to clinical signs of intracranial hypertension. They were evaluated using an imaging protocol that showed dilatation of the ventricular system and retrograde migration of the distal catheter in all cases. The tip of the catheter was located outside the peritoneal cavity, manifested on imaging as the "shotgun barrel sign" and "fishing hook sign." Based on these findings, surgical revision of the shunt system was indicated. Surgery: surgical approach and revision exclusively of the distal or abdominal segment of the shunt system, followed by reintroduction of the distal catheter into the peritoneal cavity, achieving secure closure and securing the catheter with a purse-string suture technique. Conclusion: retrograde migration of the distal catheter in ventriculoperitoneal shunts is a rare complication that presents characteristic features in routine studies and is easily detectable. This study proposes a surgical alternative to conventional revision, with multiple benefits and optimal outcomes.

Introduction: In patients with acute large vessel occlusion (LVO), CT angiography (CTA) or MR angiography (MRA) cannot visualize vessels distal to the occlusion (“stealth vessels”). A blind catheter procedure may increase a risk of serious complications during mechanical thrombectomy (MT). We developed a novel imaging method (counter-stealth technology: CST) to visualize stealth vessels. We aimed to evaluate whether counter-stealth vessels visualized by CST matched post-MT angiographic image. Methods: We included acute ischemic stroke patients with LVO between January 2019, and April 2024, who underwent MT and achieved successful reperfusion (TICI ≥2b). CST images were generated by manually tracing the relative high-density vessels distal to the hyperdense vessel sign on non-contrast CT images and reconstructed on the workstation. To assess anatomical consistency, we compared CST images with post-MT digital subtraction angiography (DSA). When CST images and post-MT DSA are consistent with all distal segments was visualized, it is classified as “visualized”; otherwise as “unvisualized”. The puncture to recanalization (P to R) time was compared between patients who underwent MT using with CST images generated in real time and those or without it. Results: Seventy-five patients were analyzed (56% male, a median age 81 years (IQR 71–87), a median baseline NIHSS score of 22 (IQR 13–26), with occlusion located in ICA; 22%, M1; 44%, M2; 20%, tandem lesion (ICA+M1); 5%, BA; 7%, P1; 1%). The mean CT value of stealth vessels was 39.1 (±9.5) HU. Compared with post-MT DSA, 84% of patients were classified as visualized. Based on the location of occluded vessels, the visualization rate of distal vessels were as follows: 71% (12/17) in ICA occlusion, 85% (28/33) in M1 occlusion, 83% (5/6) in M2 superior branch occlusion, 100% (9/9) in M2 inferior branch occlusion, 75% (3/4) in tandem lesion(ICA+M1), and 100% (5/5, 1/1) in both BA and P1 occlusions. P to R time showed no significant difference between CST and non-CST group in all patients, however, when limited to junior certified operators (n=43), it tended to have a shorter in CST group (n=25) than non-CST group (n=18) (41 min vs 48 min, p=0.91). Conclusions: CST enabled visualization of distal vessels in 84% of acute LVO cases. CST is useful tool for distal catheter navigation, especially for the junior operator.

Hydrocephalus management generally requires the implantation of a cerebrospinal fluid (CSF) shunt system that includes a ventricular catheter, a mechanical valve to regulate CSF flow, and a distal catheter that diverts the CSF to another site in the body, most commonly the peritoneal cavity. Despite advancements, approximately 40% of these shunts fail within two years, primarily due to catheter occlusion caused by cell attachment and cellular debris. Previous strategies, including polyvinylpyrrolidone (PVP) coatings aimed at reducing bacterial adhesion, have not significantly mitigated occlusion rates in clinical settings. This study explores the development of ventricular shunt catheters with a multilayered fibrous web using electrospinning technique in an effort to mitigate cellular attachment and enhance shunt longevity. Commercial silicone catheters were coated with medical-grade polyurethane material and evaluated for cellular adhesion using human astrocytes and choroid plexus epithelium (ChPE). Cells were visualized through DAPI staining and immunolabeling, and cell counts were quantified using ImageJ. Results demonstrated a significant reduction in cellular adhesion on web-spun catheters compared to uncoated controls, with normalized astrocyte densities decreasing from 37.10 ± 18.44 to 24.39 ± 16.68 [cells/mm2] (p = 0.0329). These findings suggest that web-spun coatings hold promise for improving the reliability and lifespan of shunt systems by mitigating cellular occlusion.

BACKGROUND The main problems encountered during postoperative follow-up after ventriculoperitoneal shunt surgeries are ventriculoperitoneal shunt malfunction and related complications. One of the reasons for malfunction is problems with the distal catheter. This study aimed to analyze pediatric cases and establish whether there is a link between a history of abdominal surgery and the need for shunt revision. METHODS We conducted a retrospective analysis of 138 pediatric patients who underwent surgery at our institution between 2010 and 2018. RESULTS In the first year postoperatively, 33.2% of the patients required shunt revision. Furthermore, we found a significant relationship between a history of abdominal surgery and the requirement for shunt revision (p &lt; 0.0001). Additionally, the length of the proximal catheter inside the ventricles appeared to affect the need for shunt revision (p &lt; 0.001). CONCLUSION Similar to other studies, we believe that our findings show that a history of abdominal surgery impacts the need for shunt revision. This contributes to existing literature on the topic.

Radial access has become more common among interventionalists for neurointerventional procedures due to lower complication rates and patient comfort.1, 2 However, rare but serious complications such as catheter fracture and retention require recognition and investigation of advanced retrieval strategies.3 We present a two-stage case involving a patient in their 70s who initially underwent successful mechanical thrombectomy for left M1 occlusion. Hours later, new onset of neurological deficits led to repeat digital subtraction angiography via right radial access. During catheter withdrawal and after initial medical management of suspected vasospasm, the RIST guide catheter became entrapped and fractured within the axillary artery. Transfemoral access was used to retrieve the distal catheter fragment using a snare technique. Post-retrieval imaging confirmed vessel integrity, though ulnar artery occlusion led to ischemia requiring vascular surgery. This case illustrates a rare complication of radial access and highlights suspected novel technical considerations for retrieval, rescue planning, and catheter system selection.

Background Laparoscopic access, assisted by a general surgeon, is the most commonly used technique for inserting a distal catheter during ventriculoperitoneal shunt placement. This study introduces a novel single-use trocar designed for peritoneal access, combining engineering analyses to ensure performance and safety. Methods We presented the design and bench evaluation of this new trocar concept. A Pugh matrix evaluated material and feature optimization, while failure mode and effect analysis (FMEA) identified risks such as blade dulling and spring failure. Finite element analysis (FEA) confirmed the structural integrity of the trocar. Results The FEA confirmed the structural integrity of the trocar, demonstrating high load capacities of 1655.3 N for the shaft, 503.4 N for the cannula, and 2799.12 N for the handle with minimal deformation and a high safety margin. The prototype features a sharp blade with an automatically retractable blunt tip to reduce tissue trauma and a cannula with a side slit for catheter insertion. Using sausage casing to simulate the peritoneum, sharpness testing showed a breakthrough force of 2.98 N compared to 2 N for the Versastep trocar (Medtronic, Minneapolis, MN). Conclusions The assessment and conceptualization of this new trocar showed reliability, a low risk of component failure, and good sharpness performance after multiple laboratory tests. The self-retractable tip provides a safety profile during insertion into the peritoneal cavity. Further testing in vivo is needed.

Introduction. Ventriculomegaly causes compression within the cranial vault, which increases intracranial pressure and leads to severe brain damage. Usually progressive. if untreated, may be fatal. Case. 3-month-old male child with increasement of head circumference for 2 months. Fever, cough, cold, vomiting, seizure was not found. MRI show extensive dilatation of ventricular system wide-open foramen of Luschka and Magendie with thinning of cerebral cortex and also global ischemic hypoxia. Discussion. The CBF is regulated by the Monroe-Kellie doctrine which state that space of the cranial cavity is fixed in volume. Congenital hydrocephalus occurs in one in 500-1000 babies born in the United States. Lipid peroxides, formed by oxygen free radical damage to membranes, have been detected in hydrocephalic brains by detection of thiobarbituric acid reactive substances. The mechanism of periventricular axon damage includes calcium mediated activation of proteolytic calpains that damage cytoskeletal proteins, similar to the processes that follow acute traumatic or ischemic injury. The gold standard permanent treatment for hydrocephalus is CSF diversion by placement of a shunt. A shunt has three basic component parts: a ventricular catheter placed in the lateral ventricle, a valve regulating the flow of CSF out of the brain, and a distal catheter that terminates in a cavity. The most common shunt, a ventriculoperitoneal shunt (VPS), has been well accepted since its inaugural use. Surgical treatment is associated with a 50% reduced risk of death overall

BackgroundCompared with transfemoral access (TFA), transradial access (TRA) has been widely used in neurointervention, as it has a relatively low rate of access-site complications. However, the method still has several restrictions, particularly with regard to selective angiography. This study aimed to evaluate the technical feasibility and procedural performance of a combined catheter technique designed to facilitate complete six-vessel selective cerebral angiography via TRA.MethodsWe prospectively studied patients who underwent TRA selective cerebral angiography with the combined catheter technique between January 2023 and September 2023. Clinical characteristics, procedural details, complications, and outcomes at discharge were collected. A descriptive analysis was performed.ResultsA total of 48 patients underwent TRA angiography using the combined catheter technique, 15 of whom were male. The median age of the patients was 54.81 ± 13.62 years (30–82). The intermediate or distal catheter types used in patients were Tethys in 27 cases, Envoy DAXB in 6 cases, Envoy DA in 6 cases, and Navien in 9 cases. All patients successfully received selective six-vessel angiography, including bilateral internal carotid arteries (ICAs), external carotid arteries (ECAs), and vertebral arteries (VAs), and completed the follow-up neurointervention procedure. Image quality scores for the arterial phase, capillary apparatus, and venous phase were all approximately 15, which indicates that all patients showed superior visualization of the vasculature. Average selection times per vessel were 230.50 ± 72.80 s (124–395).ConclusionIn this small single-center feasibility series, the combined catheter technique for six-vessel TRA cerebral angiography appeared technically feasible and safe, but these preliminary findings require confirmation in larger comparative studies.