Roadmap Guided Direct Percutaneous Vertebral Artery Puncture for Mechanical Thrombectomy of Acute Basilar Artery Occlusion: A Technical Case Report and Review of the Literature

Access techniques for mechanical thrombectomy normally include percutaneous puncture of the common femoral or, more recently, the radial artery. Although target vessel catheterization may frequently not be devoid of difficulties via both routes, the vast majority of mechanical thrombectomy (MT) cases can be successfully managed. However, in a significant minority of cases, a stable target vessel access cannot be reached resulting in futile recanalization procedures and detrimental outcomes for the patients. As such, in analogy to direct carotid puncture for anterior circulation MT, direct vertebral artery (VA) puncture (DVP) is a direct cervical approach, which can constitute the only feasible access to the posterior circulation in highly selected cases. So far, due to the rarity of DVP, only anecdotal evidence from isolated case reports is available and this approach raises concerns with regard to safety issues, feasibility, and technical realization. We present a case in which bail-out access to the posterior circulation was successfully obtained through a roadmap-guided lateral direct puncture of the V2 segment of the cervical VA and give an overview of technical nuances of published DVP approaches for posterior circulation MT.

Ultrasound guided direct puncture percutaneous nephrostomy: a single tertiary centre observational study

Background: Percutaneous nephrostomy (PCN) is indicated to drain the upper urinary tract collecting system in cases of obstruction. Objective of our study is to evaluate the safety and efficacy of Ultrasound guided direct puncture PCN in our populations.Methods: This observational study was conducted from May 2020 to April 2021in department of urology and renal transplant. The total 65 patients with upper urinary tract obstruction requiring PCN were enrolled. All parameters were recorded and statistical analysis was performed using the Statistical package for the social sciences (SPSS 16.0) for windows.Results: In our study Ca Cervix with ureteric infiltration (35%) was the most common indication for PCN tube placement. Majority of patients (83%) had Grade IV and Grade III hydroneprosis. Single attempt for tube placement was sufficient most of the time in (86% cases). Direct Puncture PCN tube placement was successful in 62 (95.4%) cases. The mean duration of procedure was 12.4 minutes. Loin pain was the most common procedure related complication observed in 58 patients. There was no evidence of visceral injury, no need of blood transfusion in post procedural duration in our study.Conclusions: USG guided direct puncture PCN technique is simple, low cost, less time consuming, less chance of loss of tract and effective procedure for drainage of urine in case of upper urinary tract obstruction. We recommended this procedure in grade III and IV hydronephrosis and this procedure suitable for developing countries like India because of procedure related low cost.

Stereotactic direct-coiling of aneurysms—a feasibility study

Aim of the study Endovascular coiling has gained worldwide acceptance in the management of intracranial aneurysms. However, not all aneurysms can be coiled. Direct aneurysm puncture with aneurysm thrombosis has been performed, using coils for extracranial aneurysms and iron filings for intracranial aneurysms. Therefore, the feasibility of stereotactic aneurysm coiling with direct aneurysm puncture using Nester-coils was studied in an in vitro model. Methods and findings Twenty-eight aneurysms measuring 9–21 mm in diameters (median 14 mm) were made using 0.1 mm vinyl film that was connected to a monometer with 73 cm of water column. Twenty-three aneurysms were coiled through direct puncture of the aneurysms using a stereotactic frame. Five were coiled using a hand-held probe carrier. Statistical analysis of the data was conducted by data analysis feature of Microsoft Excel. Findings The study showed that needle puncture of the aneurysm and coiling of the aneurysm through the needle can be done with ease and without any significant fluid leak from the puncture site. It also shows that the coil will stay within the aneurysm without entering the neck. The study also shows that this method can be done using free-hand technique. Furthermore, it shows that the probe holder for the needle can also be used as an aneurysm stabilizer and as a tamponade.

Achieving Hemostasis Posttranscatheter Aortic Valve Replacement in a Patient with Aortobifemoral Bypass Graft Using Perclose Device: A Novel Technique

The presence of aortobifemoral bypass graft can complicate vascular access during percutaneous intervention. Choosing an access route for transcatheter aortic valve replacement (TAVR) in this patient population can be challenging. Access options are further limited by the presence of coexisting vascular comorbidities such as extensive peripheral artery diseases in these patients. Adequate preoperative planning to determine the suitability of different access sites is, therefore, very crucial. Our case report shows that the use of Perclose can be a viable option for achieving hemostasis after a direct puncture of an aortobifemoral bypass graft during transfemoral TAVR.

Novel Direct Superior Ophthalmic Vein Approach to Treat Anterior Condylar Confluence Dural Arteriovenous Fistula

Dural arteriovenous fistulas (DAVFs) are acquired pathological arteriovenous connections involving vessels that usually supply the meninges. A DAVF in the region of the hypoglossal canal is a rare form of fistula that involves the anterior condylar confluence or anterior condylar vein. We report a case of hypoglossal canal DAVF that was successfully embolized transvenously through a superior ophthalmic vein (SOV) approach. After failed attempts through jugular access, our patient was treated by a unique percutaneous direct puncture approach through the SOV, achieving complete obliteration of the fistula. A step-by-step description of the endovascular technique was described. The clinical course was uneventful without any new neurologic deficit. The eye symptoms and third nerve palsy had completely resolved at the 3-month follow-up visit. Hypoglossal canal DAVFs are rare and may exhibit complex venous drainage patterns. Knowledge of the complex venous anatomy is essential for planning an alternative transvenous route if the standard approach is not feasible. Xper CT (Philips Healthcare, Best, The Netherlands) is an excellent tool for identifying the exact site of the fistula as well as for confirming a safe position of the catheter tip for successful occlusion of this complex dural AV fistula.

Percutaneous closure of left ventricular pseudoaneurysm using simultaneous transseptal and transapical approach: a case report

Background Left ventricular (LV) pseudoaneurysm (PSA), also referred to as contained LV wall rupture, is a clinically uncommon but potentially life-threatening condition that can occur after myocardial infarction or cardiac surgery. If the anatomic characteristics of LV PSA are not eligible for the transfemoral approach, percutaneous closure of LV PSA can be technically difficult and appropriate approach selection may contribute to procedural success. Case summary An enlarging LV PSA was discovered in a 65-year-old man with Marfan syndrome and three prior cardiothoracic surgeries. Arterial access was not possible due to invagination of the previously placed surgical graft in the descending thoracic aorta. This was managed with a novel approach of simultaneous transseptal LV access and direct puncture of PSA through the chest wall followed by a vascular plug placement. Discussion This case demonstrates that percutaneous LV PSA closure using a hybrid approach of transseptal and direct apical puncture is a feasible and effective alternative for high-risk surgical candidates, although the anatomic characteristics are unsuitable for the transfemoral approach.