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Purpose: Anatomical factors involved in the difficulty of inserting a guiding catheter (GC) into the aortic arch include marked arteriosclerosis with severe vessel tortuosity and type-3/bovine aortic arches. For patients with such factors, we have inserted a balloon guiding catheter (BGC) using the balloon-inflation anchoring technique (BIAT). In this study, we introduce the BIAT, and examine its usefulness. Subjects and Methods:The subjects were 44 patients who underwent acute mechanical thrombectomy for occlusion of the major cerebral artery in anterior circulation between January 2014 and February 2016. Of these, the BIAT was used for BGC insertion in patients, with the above anatomical factors, in whom it was difficult to insert a BGC using the standard method. The BIAT is a technique with a BGC in which an inner catheter is guided to the peripheral side by dilating/anchoring a balloon at maximum at the origin of the brachiocephalic trunk or left common carotid artery, and, subsequently, a BGC is guided to the target blood vessel by slightly deflating the balloon as a flow-guide. Results:Of the 44 patients, BGC insertion was difficult in eight patients (18%). The mean age of the other patients (control group) was 68.9 years, whereas that of the eight patients was 79.7 years, being significantly more advanced (p = 0.025). The BIAT facilitated BGC insertion in all patients, and the technical success rate was 100%. There were no procedure-related complications. The mean interval from the start of femoral artery puncture until BGC insertion was 15.7 and 20.3 minutes, respectively, in the control and BIAT groups. There was no significant difference between the two groups (p = 0.35). Conclusion:In 18% of patients who underwent acute mechanical thrombectomy, BGC insertion was difficult. In this group, the proportion of elderly patients was significantly higher. The BIAT facilitated BGC insertion in all patients. The mean interval from the start of puncture until BGC insertion was 20 minutes; a BGC could be guided in a relatively short period. This procedure may be particularly useful for acute mechanical thrombectomy, of which the duration directly contributes to the outcome.Keywords▶ balloon-inflation anchoring technique, bovine aortic arch, type-3 aortic arch, acute ischemic stroke, thrombectomy

We report a case of cerebral infarction with mechanical reperfusion therapy for tumor embolism caused by lung cancer. Case Presentation: The patient was a 72-year-old man. We performed emergency mechanical thrombectomy alone for acute left internal cerebral artery (ICA) occlusion and achieved complete reperfusion at the fifth pass with Trevo 4 × 20 mm. Pathologically, the embolus was diagnosed as squamous cell carcinoma. In chest contrast CT, lung cancer invaded the left atrium and pulmonary vein, diagnosed as tumor embolism by this invading tumor. Conclusion: We experienced a very rare case of tumor embolism caused by lung cancer. Although it was difficult to re-canalize, the strut structure of Trevo and push and fluff technique may have been effective against the hard embolus.

Objective: Vertebral arteriovenous fistula is a rare entity caused primarily by trauma and is known to occur iatrogenically after penetrating trauma of the neck and surgery of the cervical spine. We present a case of iatrogenic vertebral arteriovenous fistula that was caused by erroneous jugular vein puncture and could be radically treated by target embolization after localizing the shunt points using high-resolution cone-beam computed tomography (HR-CBCT) with a review of the literature. Case Presentation:A 76-year-old woman with a history of coronary artery disease treated with percutaneous intervention underwent scheduled cardiac catheterization by the right radial artery and right internal jugular vein approaches.Following several test punctures of the right cervical region, a 6 Fr sheath was placed in the right jugular vein, but she began to note tinnitus around this time. As vascular bruit was heard in the neck, the patient was referred to our hospital.By MRI and angiography, left vertebral arteriovenous fistula was diagnosed. Two shunt points could be identified by preoperative HR-CBCT. Trans-arterial target embolization was performed on the vein side across the shunt points, resulting in the disappearance of the shunt flow with tinnitus and vascular bruit. Conclusion:A case of iatrogenic vertebral arteriovenous fistula that could be radically treated by trans-arterial target embolization was reported. HR-CBCT was useful for the localization of the shunt points.

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