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Treatment of giant basilar aneurysm presents a major treatment challenge, especially in the pediatric population. Morbidity and mortality approach 80 and 30%, respectively. Both reconstructive and deconstructive techniques are associated with high rates of complete occlusion and good neurological outcomes. We report a 14-year-old male with a giant basilar trunk aneurysm treated with an endovascular approach. Clinical symptoms began following an ischemic stroke 2 weeks prior to admission. Endovascular treatment was performed through a reconstructive technique by single flow diverter device (FDD) in the basilar artery; however, this technique failed. At 1-year follow-up, without additional endovascular treatment, the mid-basilar artery and aneurysm were occluded, with vertebrobasilar flow maintained through collaterals from the right posterior communicating artery. We present a challenging management of giant basilar aneurysm in a pediatric patient experiencing a failure of FDD deployment; however, we highlight the importance of collateral flow development in progressive occlusions.

Treatment of giant basilar aneurysm presents a major treatment challenge, especially in the pediatric population. Morbidity and mortality approach 80 and 30%, respectively. Both reconstructive and deconstructive techniques are associated with high rates of complete occlusion and good neurological outcomes. We report a 14-year-old male with a giant basilar trunk aneurysm treated with an endovascular approach. Clinical symptoms began following an ischemic stroke 2 weeks prior to admission. Endovascular treatment was performed through a reconstructive technique by single flow diverter device (FDD) in the basilar artery; however, this technique failed. At 1-year follow-up, without additional endovascular treatment, the mid-basilar artery and aneurysm were occluded, with vertebrobasilar flow maintained through collaterals from the right posterior communicating artery. We present a challenging management of giant basilar aneurysm in a pediatric patient experiencing a failure of FDD deployment; however, we highlight the importance of collateral flow development in progressive occlusions. [ABSTRACT FROM AUTHOR]

Abstract Background The migration of contraceptive devices into pulmonary arteries is extremely rare, reported to be 1 in 100,000. Case presentation A 19-year-old female presented no sensation of a contraceptive implant in her arm which had been placed one year prior. A CT scan confirmed that the implant had migrated into the left lower segmentary pulmonary artery. After a multidisciplinary meeting, an endovascular approach was attempted. Following right femoral venous access, a 8F NeuronMax® introducer was placed into the left pulmonary artery under fluoroscopic guidance. The contraceptive device was removed using a 25-mm loop snare, with a proximal capture technique. The patient was discharged the following day, with no reported complications. Conclusion In cases of contraceptive device migration, the first medical decision involves deciding between removal or 'watching and waiting'. Previous reports describe two removal options: endovascular or surgical approaches. Fourteen reports have been published, with high technical success and low rates of complications. The loop snare technique is described as the optimal technique for an endovascular approach. Due to their invasive nature, surgical approaches should be reserved for cases of endovascular removal failure, after evaluating risks and benefits. Graphical Abstract

Background: The migration of contraceptive devices into pulmonary arteries is extremely rare, reported to be 1 in 100,000. Case presentation: A 19-year-old female presented no sensation of a contraceptive implant in her arm which had been placed one year prior. A CT scan confirmed that the implant had migrated into the left lower segmentary pulmonary artery. After a multidisciplinary meeting, an endovascular approach was attempted. Following right femoral venous access, a 8F NeuronMax® introducer was placed into the left pulmonary artery under fluoroscopic guidance. The contraceptive device was removed using a 25-mm loop snare, with a proximal capture technique. The patient was discharged the following day, with no reported complications. Conclusion: In cases of contraceptive device migration, the first medical decision involves deciding between removal or 'watching and waiting'. Previous reports describe two removal options: endovascular or surgical approaches. Fourteen reports have been published, with high technical success and low rates of complications. The loop snare technique is described as the optimal technique for an endovascular approach. Due to their invasive nature, surgical approaches should be reserved for cases of endovascular removal failure, after evaluating risks and benefits. [ABSTRACT FROM AUTHOR]

Pulmonary arteriovenous malformation (PAVM) is a rare vascular anomaly characterized by abnormal communication between the pulmonary artery and vein. It is a rare cause of hemoptysis. Computed tomographic angiography (CTA) has become the preferred and dependable diagnostic approach for identifying PAVM. PAVM embolization is the primary recommended treatment for this condition. We present a case of a 43-year-old male with a complex PAVM in the left lower lobe presenting with hemoptysis treated with an endovascular approach. Following the procedure, the patient's symptoms resolved.

In the context of thoracic endovascular aortic repair (TEVAR), the reconstruction of the left subclavian artery (LSA) has emerged as a crucial component in establishing a sufficient proximal landing zone. However, the technical difficulty of these procedures raises the possibility of endoleaks and neurological consequences. Single-branched stent grafts offer good anchoring and LSA flow for these patients. This study evaluates the feasibility of utilizing novel single-branched stent grafts in the treatment of distal aortic arch disease, identifying good results in the short and medium term. From September 2019 to March 2023, TEVAR and revascularized LSA were performed on ten patients at the Ospedale del Cuore—FTGM in Massa, Italy, using Castor single-branched thoracic aortic stent grafts (Microport Medical, Shanghai, China). The authors' first findings demonstrated that, after an average follow-up of one year, the Castor branching aortic stent graft system was safe and achieving an appropriate proximal landing zone and maintaining sufficient LSA perfusion was possible. With regard to the endovascular treatment of distal aortic arch diseases, this product offers a compelling substitute for surgery. For the purpose of assessing the long-term effectiveness of this approach, the follow-up period should be extended. [ABSTRACT FROM AUTHOR]

Aorto-enteric fistula is defined as a communication between the aorta and the gastrointestinal tract. It is a rare but life-threatening condition associated with almost 100% mortality without prompt surgical intervention. The most common type of aorto-enteric fistula is the aorto-duodenal fistula. Upper gastrointestinal bleeding is the most common presentation, ranging from a minor haemorrhage to massive life-threatening bleeding. Computed tomography angiography is the first-line modality for imaging evaluation of suspected aorto-enteric fistula. Surgical treatment of this condition may be open aortic repair, in situ graft replacement if present, or placement of an extra-anatomical bypass. We present our case of a 71-year-old woman with infected aorto-aortic graft complicated by aorto-duodenal fistula. The patient was successfully treated by aortic Zenith Cook cuff endovascular placement in the emergency setting as a life-saving treatment and a bridge solution to elective surgery.

Although the incidence of chronic mesenteric ischemia (CMI) is uncommon, it could become life threatening. With improvements in diagnostic imaging and endovascular therapy over the past few decades, the treatment of CMI has evolved. Even though endovascular revascularization for CMI is prominent, it is unclear if the early advantages outweigh the long-term patency rates. This study conducts a systematic review and meta-analysis to present comprehensive insights into the validity of endovascular revascularization versus open revascularization as effective therapeutic modalities. Studies up to 2022 were searched in MEDLINE, Cochrane Database of Systematic Reviews, Scopus, and Embase. Additionally, references from earlier studies and review papers were manually searched for additional relevant reports. At least two authors examined all the results, making sure they fit the inclusion and exclusion criteria. In the event of disagreement, the authors were able to reach an understanding. Open revascularization is superior to endovascular approaches in maintaining vessel patency and reducing symptoms over the long term. Perioperative problems are more common in patients undergoing open procedures. Each patient's anatomy and physiology call for a different revascularization approach to be applied in treating this condition.

Background: Spinal arteriovenous malformations (AVMs) are rare vascular lesions presenting either with subtle progressive myelopathy or acute intramedullary/subarachnoid hemorrhage with associated neurological deficits. Far more uncommonly, AVMs are associated with intra-nidal aneurysms, which provide a further challenge in their management. Nevertheless, if untreated, these lesions lead to severe disability with a poor percentage of neurological recovery. Due to the lack of general guidelines, a neurosurgical and endovascular multidisciplinary approach is mandatory to achieve the best outcome in the management of such conditions. Case description: We provide a case of a 12-year-old girl presenting with a history of progressive lower limbs hyposthenia and sphincter dysfunction, presenting with acute excruciating back pain. Radiological assessments revealed a thoracic anterior intramedullary AVM associated with intranidal aneurysm, determining spinal cord compression. Discussion and conclusions: After a multidisciplinary evaluation, patient underwent a microsurgical resection of the lesion, with exclusion of the lesion from the spinal circulation and spinal cord decompression. On three-months neuroradiological follow-up, complete refilling of the spinal aneurysm was detected, and patient underwent a new microsurgical approach. Definitive exclusion of the vascular lesion was then achieved. Critical discussion of the choice of treatment along with a review of the pertinent literature is provided.

Aortocaval fistulas (ACFs) are rare complications of abdominal aortic aneurysms (AAA), with an incidence of 0.22% to 6.04%, associated with a significant increase in mortality rate because of both their direct clinical repercussion and the technical difficulty involved in their treatment. Owing to technical limitations related to the open treatment of AAA with ACFs, as well as their associated morbidity and mortality rates, endovascular treatment is an important option to consider.However, under such clinical situations, the morphology of the aneurysm and the possibility of endoleak may present as limitations to an endovascular approach, as the endoleak is seen as the most frequent complication in the treatments of AAAs.Herein, we report the case of a patient who underwent endovascular treatment with an endoprosthesis for an infrarenal abdominal aortic aneurysm fistulized to the inferior vena cava, associated with a type III endoleak correction.The hemodynamic behavior of the fistula described in this case resembled that of a high-output fistula. ACF diagnosis is preferably made by contrast computed tomography, where early presence of contrast in the venous system and loss of space or abnormal communication is detected between the two vessels involved; in this case, the abdominal aorta and inferior vena cava (IVC). The treatment is surgery through ACF and aneurysm repair. We report the case of a patient who underwent endovascular correction of AAA with ACF, and presented, after 4 months, with the need for reintervention due to a type III endoleak. This case shows two complications in the same patient, a rare situation in the medical literature.

Hepatic artery pseudoaneurysm is a rare arterial disease. This case report describes a patient with hepatic artery pseudoaneurysm who presented with recurrent epigastric pain over a 4-month period. Computed tomography angiography (CTA) showed aneurysmal enlargement of the hepatic artery measuring 55 mm × 46 mm. The angiographic information is as follows: (1) the common hepatic artery originated from the superior mesenteric artery; (2) the proper hepatic artery originated from the common hepatic artery; (3) the proper hepatic aneurysmal disease had no collateral circulation. After careful consideration, the patient underwent an open surgical repair (OSR). The patient recovered well without any associated complications. The 1-year follow-up of patients did not reveal any relevant complications. The treatment choice, puzzles, and reflections of this case are all discussed in this article.

Percutaneous vertebroplasty has emerged as an increasingly popular intervention for managing a variety of common spinal conditions. Nevertheless, kyphoplasty cement can accidentally leak into paravertebral venous plexus, then travel to the right heart chambers through the venous system. We report an exceedingly rare case of an intracardiac cement embolism, likely an inadvertent complication of a recent percutaneous lumbar vertebroplasty. A mobile mass was incidentally found during a cardiac catheterization procedure, most likely in right atrium. Subsequent computed tomography angio chest and cardiac imaging confirmed a floating foreign body in the right atrium, which was then retrieved successfully through an endovascular approach. Gross examination of the removed body confirmed a bone cement-like material. Intracardiac cement embolism warrants serious attention as it may result in catastrophic cardiac complications. Intracardiac cement embolism is an extremely rare, but potentially life-threatening complication after percutaneous vertebroplasty. The bone cement fragments accidentally leak into paravertebral plexus and then via venous system into the right-sided cardiac chambers and pulmonary arteries. [ABSTRACT FROM AUTHOR]

The past decade has witnessed an explosion in applications for neural recording and stimulation in the treatment of clinical disorders. Neuromodulatory approaches are now a mainstay of care for essential tremor and Parkinson’s disease, and are expanding rapidly into a wide range of other neurological and psychiatric diseases. In parallel, advancements in endovascular approaches to cerebrovascular diseases have resulted in minimally invasive techniques that deliver devices to neural tissue in the central and peripheral nervous systems, with significantly improved safety and efficacy. In this review, we discuss the history of endovascular neural recording and stimulation, its current progress, and applications for neurological disease.

The past decade has witnessed an explosion in applications for neural recording and stimulation in the treatment of clinical disorders. Neuromodulatory approaches are now a mainstay of care for essential tremor and Parkinson's disease, and are expanding rapidly into a wide range of other neurological and psychiatric diseases. In parallel, advancements in endovascular approaches to cerebrovascular diseases have resulted in minimally invasive techniques that deliver devices to neural tissue in the central and peripheral nervous systems, with significantly improved safety and efficacy. In this review, we discuss the history of endovascular neural recording and stimulation, its current progress, and applications for neurological disease. [ABSTRACT FROM AUTHOR]

Many developments were made in the area of endovascular treatment of intracranial aneurysms, but this procedure also requires a good assessment of vascular anatomy prior to intervention. Seventy-six cases with brain aneurysms were selected and 1:1 scale 3D printed models were created. We asked three interventional neurosurgeons with different degrees of experience (ten years, four years, and a fourth-year resident) to review the cases using CTA (computed tomography angiogram) with MPR (multiplanar reconstructions) and VRT (volume rendering technique) and make a decision: coil embolization or stent-assisted coil embolization. After we provided them with the 3D printed models, they were asked to review their treatment plan. Statistical analysis was performed and the endovascular approach changed in 11.84% of cases for ten-year experienced neurosurgeons, 13.15% for four years experienced neurosurgeon, and 21.05% for residents. The interobserver agreement was very good between the ten years experienced interventionist and four years experienced interventionist when they analyzed the data set that included the 3D printed model. The agreement was higher between all physicians after they examined the printed model. 3D patient-specific printed models may be useful in choosing between two different endovascular techniques and also help the residents to better understand the vascular anatomy and the overall procedure.

Iatrogenic arteriovenous fistulas (AVF) after intervertebral disc surgery are rare. The presentation can be varied from potentially fatal to those, which present years after the index surgery with features of, deep vein thrombosis, leg edema, and cardiac failure. The history and physical findings can be indicative of an AVF and the diagnosis is confirmed by computed tomography (CT) CT angiogram (CTA) or digital subtraction angiogram (DSA). Open surgery and endovascular approach can be both used for the treatment of this condition, both with good results, although the endovascular approach is associated with minimal morbidity.

A rare case of clinical complication following a percutaneous coronary intervention is presented. A femoral vascular access was chosen to treat a coronary lesion with a stent implantation. This femoral vascular access, however, resulted in a pyogenic infection of the ipsilateral hip joint that was not properly diagnosed for an extended post-interventional period. The hip joint completely deteriorated before its underlying cause was identified. This case report illustrates the importance of recognizing potential endovascular complications independently of their frequency. [ABSTRACT FROM AUTHOR]

Carotid artery dissection accounts for 20%–30% of all ischemic strokes in young patients aged <50 years. Recent guidelines on carotid disease management do not differentiate between traumatic and spontaneous dissection. We present a case of a 36-year-old male patient with the right internal carotid artery dissection treated with two XACT Abbot 6–8 mm × 40 mm stents placement after he was strangled during Krav Maga training. It is the most effective way to prevent the imminent stroke in the penumbral region. The safety and outcome of stent placement in internal carotid artery dissection remains unclear and further randomized trials are needed. [ABSTRACT FROM AUTHOR]

Background and importanceThe tendency of posterior fossa arteriovenous malformations (pfAVM) to develop associated aneurysms (AA) is a well-known phenomenon with an increased total risk of rupture. Most pfAVM and AA develop in the territory of the posterior inferior cerebellar artery while the involvement of the anterior inferior cerebellar artery (AICA) is extremely rare. We describe an unusual case of an arteriovenous malformation (AVM) supplied by the AICA with a “proximal” AA. This unique combination of vascular lesions has been reported in only four cases so far, limiting the available experience that can safely guide the therapeutic intervention.Clinical presentationThis study describes a 59-year-old female presented with a subarachnoid hemorrhage, Hunt and Hess grade 4. Angiography demonstrated an AVM fed mainly by the right AICA and draining superficially into the transverse sinus (Spetzler–Martin grade II). In addition, there was a ruptured proximal AICA aneurysm. An endovascular approach was chosen to coil the aneurysm and obliterate the AVM using ONYX in a multi-staged process. The patient recovered well without residual deficit at 6-month follow-up.ConclusionTo the best of our knowledge, this is the first report describing a proximal AICA aneurysm and AVM treated by endovascular means. The outcome was very good, considering the technically demanding location. All previously reported cases with exactly similar lesions were managed surgically, with inconclusive outcomes. The data presented in this study are meant to help in decision-making process for similar cases till more data are available.

Background and importance: The tendency of posterior fossa arteriovenous malformations (pfAVM) to develop associated aneurysms (AA) is a well-known phenomenon with an increased total risk of rupture. Most pfAVM and AA develop in the territory of the posterior inferior cerebellar artery while the involvement of the anterior inferior cerebellar artery (AICA) is extremely rare. We describe an unusual case of an arteriovenous malformation (AVM) supplied by the AICA with a "proximal" AA. This unique combination of vascular lesions has been reported in only four cases so far, limiting the available experience that can safely guide the therapeutic intervention. Clinical presentation: This study describes a 59-year-old female presented with a subarachnoid hemorrhage, Hunt and Hess grade 4. Angiography demonstrated an AVM fed mainly by the right AICA and draining superficially into the transverse sinus (Spetzler-Martin grade II). In addition, there was a ruptured proximal AICA aneurysm. An endovascular approach was chosen to coil the aneurysm and obliterate the AVM using ONYX in a multi-staged process. The patient recovered well without residual deficit at 6-month follow-up. Conclusion: To the best of our knowledge, this is the first report describing a proximal AICA aneurysm and AVM treated by endovascular means. The outcome was very good, considering the technically demanding location. All previously reported cases with exactly similar lesions were managed surgically, with inconclusive outcomes. The data presented in this study are meant to help in decision-making process for similar cases till more data are available. [ABSTRACT FROM AUTHOR]

Over three quarters of the patients that suffer an acute traumatic aortic rupture die at the scene of the accident. Traditional open surgery repair of aortic transection is associated with significant morbidity and a perioperative mortality rate as high as 50%. The high morbidity and mortality rate combined with the evolution of endovascular techniques and the many practical advantages compared to open surgery, tend to establish the endovascular technique as the favored approach for this injury pattern. [ABSTRACT FROM AUTHOR]

This investigation aimed to demonstrate the potential of intraprocedural angiographic CT in monitoring complex endovascular coil embolization of direct carotid cavernous fistulas. Angiographic CT was performed as a dual rotational 5 s run with intraarterial contrast medium injection in two patients during endovascular coil embolization of direct carotid cavernous fistulas. Intraprocedural angiographic CT was considered helpful if conventional 2D series were not conclusive concerning coil position or if a precise delineation of the parent artery was impossible due to a complex anatomy or overlying coil material. During postprocessing multiplanar reformatted and dual volume images of angiographic CT were reconstructed. Angiographic CT turned out to be superior in the intraprocedural visualization of accidental coil migration into the parent artery where conventional 2D-DSA series failed to reliably detect coil protrusion. The delineation of coil protrusion by angiographic CT allowed immediate correct coil repositioning to prevent parent artery compromising. Angiographic CT can function as a valuable intraprocedurally feasible tool during complex coil embolizations of direct carotid cavernous fistulas. It allows the precise visualization of the cerebral vasculature and any accidental coil protrusion can be determined accurately in cases where conventional 2D-DSA series are unclear or compromised. Thus angiographic CT might contribute substantially to reduce procedural complications and to increase safety in the management of endovascular treatment of direct carotid cavernous fistulas. [ABSTRACT FROM AUTHOR]

Many developments were made in the area of endovascular treatment of intracranial aneurysms, but this procedure also requires a good assessment of vascular anatomy prior to intervention. Seventy-six cases with brain aneurysms were selected and 1:1 scale 3D printed models were created. We asked three interventional neurosurgeons with different degrees of experience (ten years, four years, and a fourth-year resident) to review the cases using CTA (computed tomography angiogram) with MPR (multiplanar reconstructions) and VRT (volume rendering technique) and make a decision: coil embolization or stent-assisted coil embolization. After we provided them with the 3D printed models, they were asked to review their treatment plan. Statistical analysis was performed and the endovascular approach changed in 11.84% of cases for ten-year experienced neurosurgeons, 13.15% for four years experienced neurosurgeon, and 21.05% for residents. The interobserver agreement was very good between the ten years experienced interventionist and four years experienced interventionist when they analyzed the data set that included the 3D printed model. The agreement was higher between all physicians after they examined the printed model. 3D patient-specific printed models may be useful in choosing between two different endovascular techniques and also help the residents to better understand the vascular anatomy and the overall procedure. [ABSTRACT FROM AUTHOR]

Type-B aortic dissection in a patient affected by Takayasu disease is a rarely described condition and its management can be challenging. A 47-year-old woman with Takayasu aortitis and previous aortic valve and ascending aorta replacement was admitted to hospital for type-B aortic dissection. The recent instabilization of aortic disease, the persistence of episodes of transient chest pain and the largest size of the aneurismatic tract of thoracic descending aorta rendered an invasive approach mandatory. Since the patient presented a complete bilateral occlusion of the subclavian artery just after the origin of the vertebral artery and a subcritical, smooth, bilateral stenosis of the common carotid artery, a custom-made endograft with left subclavian artery branch was successfully positioned, thus allowing the preservation of antegrade left vertebral circulation. This is the first case reporting an entirely endovascular exclusion of type-B dissection in a patient affected by Takayasu aortitis using a custom-made endograft with a subclavian branch allowing the preservation of the antegrade flow to left vertebral artery., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The evaluation and management of patients with abdominal vascular trauma or injury requires immediate and effective decision-making in these unfavorable circumstances. The majority of these patients arrive at trauma centers in profound shock, secondary to massive blood loss, which is often unrelenting. Moreover, ischemia, compartment syndrome, thrombosis, and embolization may also be life threatening and require immediate intervention. To minimize the risk of these potentially lethal complications, early understanding of the disease process and emergent therapeutic intervention are necessary. In the literature, the management of acute traumatic vascular injuries is restricted to traditional open surgical techniques. However, in penetrating injuries surgeons often face a potentially contaminated field, which renders the placement of prosthetic grafts inappropriate. Currently, however, there are sparse data on the management of vascular trauma with endovascular techniques. The role of endovascular technique in penetrating abdominal vascular trauma, which is almost always associated with severe active bleeding, is limited. It is worth mentioning that hybrid operating rooms with angiographic radiology capabilities offer more opportunities for the management of this kind of injuries by either temporary control of the devastating bleeding using endovascular balloon tamponade or with embolization and stenting. On the other hand, blunt abdominal injuries are less dangerous and they could be treated at most times by endovascular means. Since surgeons continue to encounter abdominal vascular trauma, open and endovascular techniques will evolve constantly giving us encouraging messages for the near future.

This video depicts a step-by-step description of a totally endovascular approach to treat a patient with thoracoabdominal aneurysm, using a branched stent-graft system. We compare the pre and post-operative computerized tomography and show 3D illustrations and real-life images of the technique.