Proximal Flow Control Research Articles

Safety and effectiveness of emergency carotid artery stenting for a high-grade carotid stenosis with intraluminal thrombus under proximal flow control in hyperacute and acute stroke

BackgroundA study was undertaken to investigate the feasibility, safety and effectiveness of emergency carotid artery stenting (eCAS) for a high-grade carotid stenosis with intraluminal thrombus (ILT) with or without proximal...

0.035-inch Non-Detachable Fibered CoilでInternal Trappingを施行したCarotid Blowout Syndrome：症例報告

●Abstract● Objective: We report a case of carotid blowout syndrome (CBS) treated by internal trapping using 0.035-inch non-detachable fibered coils. Case presentation: A 54-year-old man presented with massive hemorrhage from a skin defect in the neck 12 years after radical neck dissection and chemoradiation therapy for a right submandibular gland adenocarcinoma. Emergency tracheostomy was performed and gauze compression resulted in hemostasis. CT angiography revealed a pseudoaneurysm of the right cervical carotid artery. In addition, the right external carotid artery was occluded. Under the diagnosis of impending CBS, we performed endovascular treatment on an emergency basis. Since the patient tolerated temporary balloon occlusion of the right common carotid artery, internal trapping using 0.035-inch non-detachable coils was performed under proximal flow control. The right carotid artery was successfully occluded without any neurological deficit. Conclusion: Internal trapping using 0.035-inch non-detachable fibered coils is an effective treatment for CBS. ●Key Words● carotid blowout syndrome, internal trapping, 0.035-inch non-detachable fibered coil

脳動脈瘤手術合併症の回避と予防 未破裂脳動脈瘤治療にかかわるさまざまなトラブルへの対処と回避方法

We report intraoperative difficulties we have encountered during clipping surgery for unruptured cerebral aneurysms. There is a low risk of intraoperative rupture, but when it occurs, it can be managed either by tentative clipping or proximal flow control. The risk of aneurysm rupture can be decreased by gentle manipulation of the aneurysm, as well as full mobilization of the aneurysm and its neighboring vessels. Adhesions of vascular structures, arteries, and/or veins can be separated from the aneurysm in almost all cases with careful and sharp dissection. Injuries to perforating vessels are the most common problems. The risk of permanent injury can be reduced by combining multiple monitoring methods, especially MEP (motor evoked potential) and micro-Doppler. It is vitally important that we be aware of the difficulties that may occur during surgery and develop methods to avoid or manage them.

以前にかけたＣｌｉｐを外すテクニック

We describe techniques for removing previously placed clips. First, the parent artery should be secured to effect proximal flow control. Adherent tissues are dissected by sharp dissecting method using a small knife or microscissors. Then, we open the blade of the clip as little as possible using the clip applier, and the aneurismal clip can be carefully slid out along the line where the clip blade had been. Rough surgical technique might result in rupture of aneurysms. Bypass is also helpful to reduce the risk of ischemia during proximal flow control.

通常の後交通動脈および前脈絡叢動脈分岐部内頚動脈りゅう手術のｐｉｔｆａｌｌとその対策

Internal carotid (IC) aneurysms arising from the bifurcation of the posterior communicating (Pcom.) and anterior choroidal (Achor.) arteries are common, but carry a risk of intraoperative massive bleeding and ischemia of perforators territory those the patients' outcome worse. Proximal flow control is important to reduce the risk of rupture aneurysms during dissection and clipping. The internal carotid artery of the supraclinoid portion is sometimes arteriosclerotic and inadequate to place the temporary clip. Therefore we sometimes perform proximal flow control at the cervical carotid artery. Use of the J-shape clip to avoid the origin of the perforating artery to be occluded and anterior temporal approach for the fundus of aneurysms projecting posterior are also useful. We investigated 135 consecutive aneurysm surgeries for the IC aneurysms arising from the bifurcation of the Pcom. and Achor. arteries as regard to the use of proximal flow control and occurrence of the ischemic complications in the perforators' territory. Proximal flow control was performed in 62 surgeries for ruptured aneurysms and 13 for un-ruptured aneurysms. In 40 of all 75 surgeries where proximal flow control was performed, the carotid artery was clamped at the extracranial cervical portion. The main reason for this was arteriosclerosis of the intracranial internal carotid artery to be clipped with temporary clips. Each occlusion time was less than 10 minutes in most cases. Infarction of the perforator territory occurred in 4 of 92 surgeries (3.7%) for ruptured aneurysms and in none of 43 surgeries for non-ruptured aneurysms. Proximal flow control is important for the safe treatment of usual IC aneurysms. Prevention of injury to the Achor. artery is also beneficial to a favorable outcome.

Transcatheter Occlusion of Blalock-Taussig Shunts: Technical Options

This review of findings in children undergoing transcatheter shunt occlusion was carried out to describe and compare the results of four different embolization techniques. A retrospective review of clinical, radiologic, and cardiac catheterization records was carried out for 18 consecutive pediatric patients referred for Blalock-Taussig shunt occlusion at one institution. Technical aspects included the use of three devices--steel wire/fiber coils, detachable latex balloons, and ductal occlusion devices--and four techniques--direct transarterial placement, transarterial placement with proximal or with distal flow control, and transvenous delivery. Occlusion of the shunt was attempted in 17 patients (mean age, 6.2 years). Shunt occlusion was successful in 14 patients. Embolization of a device into the pulmonary circulation occurred in five patients, and was most frequent with transarterial delivery without flow control or with proximal flow control (in four of six). Transarterial occlusion with distal flow control and transvenous delivery of ductal occluder devices were the most reliable methods of occluding shunts without distal stenosis, with success in eight of nine cases with the former technique and all of three with the latter technique. Transarterial embolization of Blalock-Taussig shunts carries a risk of device embolization to the pulmonary circulation; this is best avoided by the use of distal flow control or transvenous placement of a ductal occlusion device.

Angioscopy in endovascular surgery: recent technical advances to enhance intervention selection and failure analysis.

Recent technical and procedural modifications have greatly enhanced the usefulness of angioscopy during angioplasty. A pulsed irrigation system, proximal and distal blood flow control by pressure, and attention to sheath/vessel diameter ratio were incorporated into a study in which angioscopy was used for pretreatment assessment in 23 patients with symptomatic peripheral vascular disease presenting for initial (8 patients) evaluation or repeat treatment (15 patients) following a previous vascular procedure. Twenty-five lesions were examined with a 2.3 mm flexible angioscope equipped with an irrigating lumen; there were no complications attributable to angioscopy. The angioscope was useful in the characterization of lesions for selection of the recanalization technique. Lesions more amenable to initial atherectomy were visualized in 12 patients; 7 occlusions were successfully treated with laser/balloon angioplasty, with angioscopy assisting in probe and/or wire passage in 4 cases. Three late reocclusions were identified angioscopically as due solely to thrombosis, indicating the need for thrombolytic therapy. Angioscopy also identified 4 cases of incomplete recanalization despite a satisfactory arteriographic image. Angioscopy was also used to evaluate stenotic lesions unaccompanied by thrombus formation in patients previously treated with laser-assisted angioplasty. Histologic evaluation of the biopsied plaques identified intimal hyperplasia as the etiology, matching identically similar specimens harvested from a lesion treated with balloon dilation only.