Cavernous sinus dural arteriovenous fistula accessed through a straightened superficial temporal vein

Background: Transvenous embolization through the inferior petrosal sinus (IPS) is the most common treatment procedure for cavernous sinus dural arteriovenous fistula (CSDAVF). When the IPS is inaccessible or the CSDAVF cannot be treated with transvenous embolization through the IPS, the superficial temporal vein (STV) is used as an alternative access route. However, the approach through the STV is often challenging because of its tortuous and abruptly angulated course. We report a case of recurrent CSDAVF which was successfully treated using a chronic total occlusion (CTO)-dedicated guidewire and by straightening the STV. Case Description: A 63-year-old woman was diagnosed with CSDAVF on examination for oculomotor and abducens nerve palsy. She was initially treated with transvenous embolization through the IPS. However, CSDAVF recurred, and transvenous embolization was performed through the STV. A microcatheter could not be navigated because of the highly meandering access route through the STV. By inserting a CTO-dedicated guidewire into the microcatheter, the STV was straightened and the microcatheter could be navigated into a shunted pouch of the CS. Finally, complete occlusion of the CSDAVF was achieved. Conclusion: If an access route is highly meandering, the approach can be facilitated by straightening the access route with a CTO-dedicated guidewire.

Dual-Layer Spectral CTA for TAVI Planning Using a Split-Phase Protocol and Low-keV Virtual Monoenergetic Images: Improved Image Quality in Comparison with Single-Phase Conventional CTA

Purpose Adaptation of computed tomography protocols for transcatheter aortic valve implantation (TAVI) planning is required when a first-generation dual-layer spectral CT scanner (DLCT) is used. The purpose of this study was to evaluate the objective image quality of aortic CT angiography (CTA) for TAVI planning using a split-phase technique with reconstruction of 40 keV virtual monoenergetic images (40 keV-VMI) obtained with a DLCT scanner. CT angiography obtained with a single-phase protocol of a conventional single-detector CT (SLCT) was used for comparison. Materials and Methods 75 CTA scans from DLCT were retrospectively compared to 75 CTA scans from SLCT. For DLCT, spiral CTA without ECG-synchronization was performed immediately after a retrospectively ECG-gated acquisition covering the heart and aortic arch. For SLCT, spiral CTA with retrospective ECG-gating was performed to capture the heart and the access route simultaneously in one scan. Objective image quality was compared at different levels of the arterial access route. Results 40 keV virtual monoenergetic images of DLCT showed a significantly higher mean vessel attenuation, SNR, and CNR at all levels of the arterial access route. With 40 keV-VMI of DLCT, the overall mean aortic attenuation of all six measured regions was 589.6 ± 243 HU compared to 492.7 ± 209 HU of SLCT (p < 0.01). A similar trend could be observed for SNR (23.6 ± 18 vs. 18.6 ± 9; p < 0.01) and CNR (21.1 ± 18 vs. 16.4 ± 8; p < 0.01). No deterioration was observed for vascular noise (27.8 ± 9 HU vs. 28.1 ± 8 HU; p = 0.599). Conclusion Using a DLCT scanner with a split-phase protocol and 40 keV-VMI for TAVI planning, higher objective image quality can be obtained compared to a single-phase protocol of a conventional CT scanner. Key Points: Citation Format

STMO-7 Usefulness of NU-KNIT in retractorless surgery for malignant glioma

On the removal of the brain tumor, securing of appropriate working corridor and the maintenance of the visibility are one of the most relevant elements regardless of tumor local existence. This is unchangeable extract in these days when a support apparatus such as navigation system and the nerve monitoring was enriched, and, in the malignant glioma that a tumor border is relatively indistinct, the importance does not change either.At our hospital, I protect the access route by two folds of coating of absorbable hemostat(Surgical NU-KNIT) and neurosurgical patties (Delicot) on the removal of the malignant brain tumor in the brain deep part instead without using as possible fixed retractor for the purpose of securing of working corridor under minimum retraction and extract deep part tumor. In this way, normal real protection, wet maintenance, maintenance of the visibility by the control of the bleeding and pressure reduction of the neighborhood organization extracting are provided, and postoperative function recovery gets an early impression. About a method of the securing of working corridor at our hospital, I inspect the usefulness and limit by showing representative cases and want to have an opinion, criticism.

Access Route for Endovascular Neurointervention - Transfemoral to Transradial: Is it Worth the Effort and are we Ready for the Change?

Transfemoral access for neurointerventions has been a time-tested technique of entering the vascular network of the body and reaching the intended targets. However, it has its own share of shortcomings in the form of long admission times leading to increased costs, patient inconvenience and local (though infrequent) adverse affects. Transradial route has taken the interventional cardiology domain by storm and is staring now at other vascular domains especially neurointervention. It has shown better outcomes than the transfemoral route in many aspects. The current article discusses the vascular access perspectives with an exhaustive overview of the transradial route concerning its historical perspectives, its requirement in the current clinical scenario, the procedure per se including the adverse effects and whether it has the real world charm to displace the transfemoral route into the backseat. Transradial access in neurointervention is here to stay, however it would require training, certain modifications in the standard catheters that one currently uses for cerebral procedures and constant practice by the operator to cross the learning curve and attain a certain level of competence before he becomes comfortable with the technique.

Abstract 1122‐000059: Considering Transcarotid Access for Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta‐Analysis and Systematic Review

Introduction : Despite the success of mechanical thrombectomy in large vessel acute ischemic stroke, there remain cases where recanalization fails due to difficult anatomic access or peripheral arterial occlusive disease. In these cases, transbrachial or transcarotid access may be considered as alternatives to the transfemoral or increasingly popular transradial route. Of these approaches, the transcarotid route has not gained prominence due to safety concerns despite its prior routine use in angiography. In this study, we conducted a systematic review and meta‐analysis of the literature in order to better summate the data on transcarotid access. Methods : Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were used in order to perform a systematic review of articles published from 2010–2020 summarizing pre‐intervention characteristics of patients undergoing mechanical thrombectomy via transcarotid puncture. We performed a meta‐analysis focused on clinical outcomes, reperfusion times (in minutes), and overall complication rates of transcarotid access for mechanical thrombectomy. Pooled analyses were performed to examine predictors of complications and outcomes. Results : Six studies describing 72 patients, out of 80 attempts at carotid access (90% success rate), were included. Age ranged from the 5th to 9th decade (median 7.5). Initial National Institutes of Health Stroke Scale (NIHSS) score ranged from 4 to 28 (median 17). Direct carotid puncture was most often used as a rescue technique (86% of patients) secondary to failed femoral access. Successful recanalization was achieved in 85% of patients. Good 90‐day outcome (modified Rankin Scale ≤2) was achieved in 27% of patients. Median carotid puncture‐to‐reperfusion time was 32 minutes (CI = 24–40, p < 0.001). Cervical complications occurred at a rate of 23% (CI = 14– 35%, p < 0.001). Only one complication resulted in a fatal outcome and only one required an intervention (each 1.4%). Use of IV thrombolysis did not significantly predict better mTICI outcome. Complications were not predicted by use of IV thrombolysis or closure method. Carotid puncture as the primary access route was associated with significantly shorter procedure times and carotid puncture as a rescue route was associated with comparable procedure times to the classic femoral access route. Conclusions : Our results suggest that, despite current concerns about the use of transcarotid access, this technique can be considered a viable backup route in cases of failed transfemoral or transradial access. Though this method requires further research to better understand the variables that might play into clinical decision‐making for its use in acute stroke management, it is a promising area of study that could allow for thrombectomy in patients where it would otherwise be aborted.

Case Report: Lithoplasty-Assisted Trans-Axillary Transcatheter Aortic Valve-in-Valve Implantation

We present the case of a severely symptomatic patient with a malfunctioning aortic bioprosthesis and severe multidistrict atherosclerosis that was addressed to our unit for transcatheter valve-in-valve implantation. The imaging and clinical assessment that led to the selection of the access route is discussed.

Thoracic Endovascular Aortic Repair With a Right Thoracotomy Approach: a Case Report

Background: The common femoral artery is usually the preferred access route for thoracic endovascular aortic repair (TEVAR). However, if access from the common femoral artery is challenging, other routes must be considered. We report a case of TEVAR performed by approaching the descending thoracic aorta with a right thoracotomy and using the descending thoracic aorta as an access route. Case presentation: A 70-year-old female was diagnosed with a descending thoracic aortic aneurysm (65 mm in diameter), a thoracoabdominal aneurysm (54 mm in diameter), and an abdominal aortic aneurysm (49 mm in diameter). Since the patient had severe chronic obstructive pulmonary disease, one-stage replacement of the thoracoabdominal aortic aneurysm was contraindicated and TEVAR on the descending aorta was selected. A strong tortuous section of the aorta—from the descending aorta to the abdominal aorta—hampered endovascular access to the site from the common femoral artery. A TEVAR approach from the abdominal aorta was also considered; however, an abdominal aortic aneurysm and a transverse colon loop stoma from an earlier surgery presented challenges to this technique. We chose to access the descending thoracic aorta with a thoracotomy from the right 6th intercostal space for TEVAR, because the access route that is not affected by the meandering of the aorta is considered to be the descending aorta with a right thoracotomy. The patient’s postoperative course was uneventful after the stent graft was placed. No complications were detected with postoperative contrast-enhanced computed tomography (CT). Conclusions: Our findings suggest that TEVAR can be performed by approaching the descending aorta from a right thoracotomy, if variations of vascular anatomy interfere with the more commonly used femoral artery approach.