Objective:Periprocedural antithrombotic management in patients with non-valvular atrial fibrillation (NVAF) undergoing carotid artery stenting (CAS) remains controversial. Although dual antiplatelet therapy is the standard regimen for CAS, its combination with a direct oral anticoagulant (DOAC) as triple therapy increases bleeding risk. On the other hand, interruption of DOAC therapy may increase thromboembolic risk. We evaluated the clinical outcomes and feasibility of an uninterrupted dual antithrombotic therapy (DAT) strategy consisting of a DOAC and single antiplatelet therapy (SAPT). Methods:We retrospectively reviewed a case series of 10 patients with NVAF treated between 2018 and 2025 who underwent CAS while continuing DOAC plus SAPT without interruption. In all cases, SAPT (clopidogrel, aspirin, or prasugrel) was initiated at least 2 weeks before the procedure. Platelet function was assessed using the VerifyNow system (Werfen, Bedford, MA, USA). We evaluated baseline clinical characteristics, antithrombotic regimens, platelet reactivity, procedural details, and periprocedural clinical outcomes. Results:The mean CHA2DS2-VASc and HAS-BLED scores were 4.4 ± 1.4 and 3.8 ± 1.0, respectively. CAS was successfully performed in all patients. One patient with elevated P2Y12 reaction units required the temporary periprocedural addition of cilostazol. No periprocedural hemorrhagic or thromboembolic complications occurred during the periprocedural period or within 3 months after CAS. Conclusion:Uninterrupted DAT with a DOAC and SAPT may be a feasible periprocedural management strategy for CAS in patients with NVAF, without the need for DOAC interruption or triple therapy.
Objective:Flow-directed microcatheters (FDMs) offer high flexibility and trackability for accessing distal arterial feeders. However, the radiopaque tip marker is small, making it difficult to identify on fluoroscopy. This study evaluated an intraoperative artificial intelligence (AI)-based system for real-time detection of FDM tip markers. Methods:We retrospectively analyzed 10 consecutive cases of middle meningeal artery embolization for chronic subdural hematoma using the AI-based system. The detection rate was evaluated on a frame-by-frame basis during microcatheter placement. Exploratory subgroup analyses were performed based on the catheter diameter (1.5 Fr vs. 1.3 Fr) and whether the microcatheter tip or guidewire tip advanced ahead during navigation. Results:Twenty-five FDM placement scenes were analyzed. Mean microcatheter navigation time was 2.1 min. The precision, recall, and detection rate of the system were 95%, 51%, and 50%, respectively; the detection rate was calculated as the proportion of true-positive frames among all analyzed frames. Although this was an exploratory subgroup analysis, the detection rate appeared higher for the 1.5-Fr microcatheters than that for the 1.3-Fr microcatheters (78% vs. 46%; p = 0.006). Furthermore, the detection rate was significantly higher when the microcatheter tip advanced ahead of the guidewire tip than vice versa (65% vs. 43%; p = 0.002). Conclusion:Although the detection rate was 50%, the AI system may help operators recognize the tip position when it becomes difficult to identify on fluoroscopy. Larger multicenter studies are required to validate these findings.
Objective:Wrist-based access for cervicocerebral angiography and neurovascular interventions is increasingly adopted as an alternative to transfemoral access, offering lower complication rates and faster recovery. In select cases, dual arterial access facilitates navigation of complex anatomy and the use of multiple devices. However, evidence supporting bilateral wrist access remains limited. We report our institutional experience (University of Pennsylvania Health System) with this approach. Methods:We retrospectively reviewed consecutive diagnostic and interventional neurovascular procedures performed using bilateral wrist access across a single university health system (September 2019-July 2025). Demographic, clinical, and procedural data were summarized, with a focus on technical considerations and outcomes. Results:Twenty procedures were performed, including 7 diagnostic and 13 interventional cases. Bilateral radial access was used in 16 cases, and ulnar access in 4. Median procedure time was 117 min for diagnostic cases and 236 min for interventional cases. The most common indication for bilateral access in diagnostic procedures was to facilitate anatomic reach for vertebral artery catheterization, while a transcirculation approach was the primary indication in interventional cases. Target vessel catheterization was achieved in 19 of 20 cases (95%). No major complications occurred. One case required conversion to femoral access due to unfavorable working angles across the aortic arch. One self-limited radial artery wire microperforation was successfully managed with catheter tamponade and conversion to ulnar access. On systematic review of follow-up imaging, 1 symptomatic radial artery occlusion was identified (1/20; 5%), managed conservatively without functional sequelae; no other access-site complications were observed. Conclusion:Bilateral wrist access is a safe and technically feasible alternative access strategy in carefully selected cases for cervicocerebral angiography and neurovascular interventions. With appropriate planning, this technique may serve as a selective alternative access strategy for complex procedures requiring dual arterial access, particularly posterior circulation and transcirculation interventions.
Objective:The natural history of intracranial arterial stenosis caused by giant cell arteritis (GCA) and the effects of therapeutic interventions remain unclear. We report a case of rapidly progressive intracranial arterial stenosis associated with GCA and discuss its clinical course and the implications for endovascular management. Case Presentation:A 75-year-old man developed multiple intracranial arterial stenoses and occlusions over several months, resulting in cerebral infarction. Percutaneous transluminal angioplasty was performed for severe stenosis of the cavernous segment of the right internal carotid artery, which exhibited delayed distal contrast opacification. Temporal artery biopsy confirmed the diagnosis of GCA. Although inflammatory markers improved with optimal medical treatment, the untreated intracranial arterial stenoses progressed rapidly, leading to extensive cerebral infarction. In contrast, no restenosis was observed at the site treated with angioplasty during the 6-month follow-up period. Conclusion:Rapidly progressive intracranial involvement in GCA may lead to a devastating clinical course, with progression of arterial stenosis occurring despite apparent control of systemic inflammation. This case highlights that intracranial arterial stenosis due to GCA can progress rapidly even under immunosuppressive therapy, underscoring the importance of serial vascular imaging and suggesting that some patients may benefit from early consideration of endovascular treatment.
Objective:Cavernous dural arteriovenous fistula (dAVF) is often treated by transvenous embolization through percutaneous routes. However, it is sometimes difficult when venous drainage flows only into leptomeningeal venous reflux. Here, we present a case of cavernous dAVF draining predominantly into the superficial middle cerebral vein (SMCV), through which endovascular coil embolization was successfully performed by direct surgical exposure. Case Presentation:A 62-year-old woman presented with left hemiparesis. Head CT revealed a right frontoparietal subcortical hematoma. Cerebral angiography showed retrograde leptomeningeal venous drainage (RLVD) caused by a right cavernous dAVF. Despite multiple percutaneous transvenous attempts, the cavernous sinus could not be accessed; therefore, a combined open surgical and endovascular approach was selected. After right frontotemporal craniotomy, the temporal cortical vein arising from a common trunk with the SMCV was preserved to reduce intra-sinus pressure and confirm fistula obliteration, with the puncture performed distal to this branch. The other drainage pathway, the SMCV, was cut down for sheath placement to secure stable access and minimize bleeding risk. A microcatheter was looped within the cavernous sinus for stability. Coil embolization was successfully completed under intraoperative digital subtraction angiography. After disappearance of shunt flow and RLVD, both the SMCV and the temporal cortical vein were coagulated and clipped. Conclusion:A hybrid surgical and endovascular approach can be an alternative method in cases when percutaneous transvenous embolization is not feasible. We review the combined surgical and endovascular approach and discuss the key technical considerations for successful implementation, including indications for the hybrid approach, operating room setup, craniotomy, sheath placement, coil embolization strategies, and closure.
Intracranial atherosclerotic disease (ICAD) is one of the important causes of ischemic stroke worldwide. With advances in patient selection, perioperative management, and endovascular device technology, endovascular therapy (EVT) has become an important research focus in ICAD as a potential adjunctive treatment strategy. This review summarizes the current global status of ICAD management, with particular attention to regional differences in epidemiological characteristics, endovascular treatment strategies, and perioperative medical management. This review may help improve understanding of the evolving treatment strategies and regional differences in ICAD management and provide references for future precision-based and individualized neurointerventional therapy.
Objective:Stent-assisted coil embolization (SAC) has expanded the treatment options for ruptured wide-neck aneurysms; however, SAC during the acute phase of subarachnoid hemorrhage (SAH) remains controversial owing to concerns regarding thromboembolic and hemorrhagic complications. This study aimed to evaluate the feasibility and safety of SAC for ruptured wide-neck aneurysms in the acute phase of SAH at a single center in Japan. Methods:Patients with ruptured wide-neck aneurysms who underwent endovascular treatment within 48 h after SAH onset between January 2015 and December 2024 were retrospectively evaluated. Wide-neck aneurysms were defined as those with a neck width of ≥4 mm or a dome-to-neck ratio of <2. Patients were divided into 2 groups: the SAC group and the non-SAC group. The primary outcome was perioperative complications. Secondary outcomes included angiographic outcomes, clinical outcomes at discharge and 1-year follow-up, and retreatment rates. Results:A total of 140 patients were included (SAC group, n = 24; non-SAC group, n = 116). Aneurysms in the SAC group demonstrated more complex morphology, particularly lower aneurysm height and smaller dome-to-neck ratios. The rates of perioperative hemorrhagic complications (12.5% vs. 9.4%) and symptomatic thromboembolic complications (8.3% vs. 8.6%) were comparable between the SAC and non-SAC groups. The immediate angiographic outcomes did not differ significantly between the 2 groups. Clinical outcomes at discharge and at 1-year follow-up did not differ significantly. Conclusion:SAC for ruptured wide-neck aneurysms in the acute phase of SAH appears to be feasible with no significant differences in perioperative complication rates or clinical outcomes compared with non-SAC treatment. With appropriate patient selection and careful antiplatelet management, SAC may be a reasonable treatment option.
Objective:Kasabach-Merritt syndrome (KMS) is a life-threatening disorder characterized by severe thrombocytopenia and consumptive coagulopathy associated with vascular tumors, typically Kaposiform hemangioendothelioma (KHE) or tufted angioma. Drug therapy is the first-line treatment, but some cases are refractory, and no established salvage therapy exists. This report describes a case of KMS resistant to multiple drug therapies in which transarterial embolization (TAE) was successfully performed. Case Presentation:A 2-month-old male infant presented with a left posterior neck mass. Examination revealed severe thrombocytopenia (5000/μL) and coagulation abnormalities. Imaging studies diagnosed KMS with KHE. Platelet counts did not improve despite sequential treatment with corticosteroids, beta-blockers, and sirolimus. TAE was indicated due to the high risk of fatal bleeding. Angiography identified feeding vessels from the posterior muscular branch of the vertebral artery and the ascending cervical artery. TAE was performed using 20% n-butyl-2-cyanoacrylate (NBCA) for the vertebral artery branch and gelatin sponge particles for the ascending cervical artery branch. Post-embolization, platelet counts normalized, and the tumor shrank. Conclusion:In a case of drug-resistant KMS, TAE effectively restored platelet counts and prevented fatal complications. When performed with appropriate embolic selection and careful complication management, arterial embolization can be a useful adjunctive treatment.
Intracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke worldwide, and is particularly prevalent in Asian populations. Patients with symptomatic severe ICAS remain at a high risk of recurrent stroke despite medical management (MM) alone, which has driven interest in elective endovascular revascularization. This review summarizes the history, evidence, and current controversies surrounding endovascular therapy for symptomatic ICAS, with emphasis on the periods before and after the pivotal randomized controlled trials, the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial and the Vitesse Intracranial Stent Study for Ischemic Stroke Therapy (VISSIT) trial. In the pre-SAMMPRIS/VISSIT era, percutaneous transluminal angioplasty (PTA) or PTA and stenting (PTAS) using coronary or dedicated intracranial stents demonstrated technical feasibility and seemingly acceptable short-term outcomes in observational studies. However, SAMMPRIS and VISSIT subsequently showed that PTAS was inferior to MM alone, largely because of high periprocedural stroke or death rates and the frequent occurrence of in-stent restenosis, establishing MM as the standard first-line treatment. Later observational studies suggested that outcomes may improve with stricter patient selection, avoidance of acute-phase intervention, adherence to on-label indications for the Wingspan system (Stryker Neurovascular, Fremont, CA, USA), and exclusion of high-risk lesion types, such as perforator-associated disease. Recent trials have renewed interest in elective endovascular revascularization. In particular, the Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis (BASIS) trial demonstrated the superiority of submaximal balloon angioplasty plus MM over MM alone, suggesting that the procedure may reduce procedural risk while preserving long-term benefits. In parallel, drug-eluting stents and drug-coated balloons have shown promise in reducing restenosis and late ischemic events, while technical innovations-such as first-balloon-then-stent approaches, novel exchange guidewires, and tailored lesion-specific device and procedural selection-may further improve safety. Although current evidence does not support PTAS as a first-line therapy for symptomatic ICAS, evolving strategies suggest that selective patients may benefit from elective endovascular revascularization. Further large-scale, well-designed studies are needed to determine the optimal candidates, timing, devices, and techniques for this treatment.
Fetal-type posterior communicating artery (PcomA) aneurysms remain a difficult subgroup in the flow-diverter era. In these lesions, the PcomA supplies a substantial portion of the posterior cerebral artery territory because the ipsilateral P1 segment is absent, hypoplastic, or functionally insufficient. The branch therefore functions as a major outflow channel, and persistent distal demand may maintain circulation through the aneurysm-neck complex after flow diversion. This review summarizes the anatomical basis of fetal-type PcomA aneurysms and the current evidence for clipping, coiling, intrasaccular devices, and flow diversion. Among PcomA aneurysms treated with flow diverters, non-fetal lesions generally show better angiographic outcomes than fetal-type lesions. In a recent meta-analysis, complete occlusion at final follow-up was 77% in non-fetal aneurysms versus 42% in fetal-type aneurysms. A multicenter comparative cohort similarly reported complete occlusion in 81.8% versus 43.7%, with a markedly shorter median time to occlusion in non-fetal lesions (6 vs. 51 months). Earlier fetal-type series often showed persistent aneurysm filling and low complete occlusion rates, whereas more recent selected cohorts have reported complete or near-complete occlusion in 60%-80% of cases, suggesting that flow diversion can still be effective in carefully selected anatomies and with tailored strategies. Overall, clipping and coiling remain important branch-preserving options, and intrasaccular treatment may be reasonable in selected lesions with favorable geometry. Flow diversion should be considered selectively, particularly for large, recurrent, broad-necked, or morphologically complex aneurysms, while recognizing that robust fetal circulation may delay or limit aneurysm occlusion. Current evidence remains constrained by small retrospective series, inconsistent definitions of fetal anatomy, and heterogeneous device strategies.
Objective:Endovascular embolization with Onyx (Medtronic, Minneapolis, MN, USA), a non-adhesive liquid embolic agent, is widely used to treat cerebral arteriovenous malformations (AVMs); however, ischemic complications remain a concern. Although aspiration of blood from a distal access catheter (DAC) after microcatheter retrieval is commonly performed in clinical practice, its mechanistic rationale has not been clarified. We report a case in which scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS) were used to evaluate whether microscopic Onyx fragments could be detected in aspirated blood. Case Presentation:A patient with a Spetzler-Martin grade III occipital AVM underwent transarterial embolization using Onyx. Retrieved microcatheters and blood aspirated from the DAC were analyzed using SEM/EDS. Tantalum-containing microscopic aggregates consistent with Onyx were identified on the microcatheter surface and in the aspirated blood. The detected fragments measured approximately 50-90 µm. In addition, a simplified experimental model demonstrated reproducible adhesion of Onyx to microcatheters and frequent detection of Onyx material within the DAC lumen. Conclusion:This case demonstrates that microscopic Onyx fragments can be detected in blood aspirated from a DAC using SEM/EDS. While the clinical significance of these findings remains uncertain, our findings suggest that microscopic Onyx-derived material may persist within the catheter system after embolization.
Objective: The occipital artery (OA) typically originates from the external carotid artery; however, rare anatomical variants exist in which it arises from the internal carotid artery (ICA). Because the OA generally has anastomoses with the deep cervical and vertebral arteries, the OA in the present case, which originated from the ICA, functioned as a collateral pathway in the setting of ICA stenosis due to this unique anatomical variant. Furthermore, it may represent a potential embolic route during carotid artery stenting (CAS). We report the hemodynamic characteristics of and treatment strategy for the present case. Case Presentation: A 65-year-old man was found to have carotid artery stenosis during a routine brain screening and was referred to our department (Department of Neuroendovascular Therapy, Yokohama Municipal Citizen's Hospital) for further evaluation. Cerebral angiography and CTA revealed severe stenosis of the right ICA, as well as a collateral pathway through which blood flowed retrogradely from the deep cervical artery through the OA into the distal segment of the stenotic ICA. It was considered that an OA, which originally arose from the ICA, had changed to retrograde flow as a collateral pathway following the development of ICA stenosis. Because distal protection alone was deemed insufficient for embolic prevention, CAS was performed under flow reversal with occlusion of the common carotid artery, ICA, and external carotid artery, and the procedure was completed without major complications. Conclusion: In cases of ICA stenosis accompanied by an OA originating from the ICA, individualized embolic protection strategies based on detailed anatomical and hemodynamic evaluation are essential, with careful consideration of the risk of embolization via collateral pathways.
Objective: This Woven EndoBridge Database (W-EB DB) study was conducted using data from a nationwide, multicenter database to evaluate the safety and efficacy of the W-EB device (MicroVention, Aliso Viejo, CA, USA; distributed by Terumo, Tokyo, Japan) for the treatment of wide-neck intracranial bifurcation aneurysms in Japanese patients. In this paper, we confirm the clinical usefulness of the W-EB device in Japanese patients based on the comparable 1-year post-procedure outcomes to those reported from overseas. Methods: This W-EB DB study was a post-marketing, open-label, non-randomized cohort study conducted using the database of the Japanese Society of Neuroendovascular Therapy (JSNET). Atotal of 128 participants (including 103 patients with unruptured aneurysms and 25 patients with ruptured aneurysms) treated with the W-EB device between December 2020 and December 2025 at any of the 12 participating centers were included in this study. Clinical data collected from the database consisted of the patient demographics, comorbidities, aneurysm characteristics (location, size, and neck width), procedural details, and follow-up outcomes. The safety endpoints were the incidences of subarachnoid hemorrhage (SAH), rebleeding, cerebral infarction, and other adverse events occurring within 1 year after the procedure. The efficacy endpoints were the aneurysm occlusion rates and retreatment rates at 180 days and 1 year after the procedure; the aneurysm occlusion status was determined in accordance with the W-EB Occlusion Scale (WOS). We used descriptive statistics to analyze the results. The research within our submission was approved by the institutional ethics review board of Kyoto University (Approval No. R2088). Results: In regard to the safety endpoints, SAH occurred in 1 patient (1.0%) with an unruptured aneurysm, and rebleeding occurred in 1 patient (4.0%) with a ruptured aneurysm. The incidence of cerebral infarction was 7.0%. Most other adverse events were mild, and no new device-related risks were identified. In regard to the efficacy of the device, at 1 year post-procedure, complete occlusion (WOS grade A or B) was achieved in 58 of 95 lesions (61.1%) and adequate occlusion (WOS grade A, B, or C) was achieved in 79 of 95 lesions (83.2%). Retreatment was needed for 5 of 126 lesions (4.0%). The safety and efficacy outcomes were comparable to those reported from multicenter studies conducted in Europe and the United States, with slightly higher complete occlusion rates and similar adequate occlusion and retreatment rates. Conclusion: Favorable safety and effectiveness of the W-EB device were observed at 1 year after device deployment in Japanese patients with wide-neck intracranial aneurysms. These findings are consistent with international reports and support the clinical utility of the W-EB device, given the low incidence of serious complications.
Objective: We report a rare case of delayed intracerebral hemorrhage that was possibly related to venous outflow impairment after transarterial embolization (TAE) with Onyx (Medtronic, Dublin, Ireland) for a tentorial dural arteriovenous fistula (DAVF). We also discuss the potential role of susceptibility-weighted imaging (SWI) in the early detection of postoperative venous circulatory disturbance. Case Presentation: A 65-year-old man with a history of atherosclerotic stroke was diagnosed with a left tentorial DAVF (Borden type III, Cognard type IV). TAE with Onyx was performed, and complete obliteration of the shunt was achieved. MRI obtained 1 day after embolization revealed FLAIR hyperintensity near the shunt point and hypointense signals on SWI, suggesting venous outflow impairment. On postoperative day 6, the patient developed a large subcortical hemorrhage that required emergency decompressive craniotomy. Follow-up angiography confirmed persistent shunt occlusion. The patient was subsequently transferred to a rehabilitation facility with a modified Rankin Scale score of 4. Conclusion: This case illustrates a rare instance of delayed hemorrhage after Onyx TAE for a tentorial DAVF, possibly related to venous outflow impairment after embolization. SWI may be a useful adjunctive imaging modality for the early detection of postoperative venous circulatory disturbance.
Objective:Futile recanalization (FR) is defined as a poor functional outcome despite successful reperfusion after mechanical thrombectomy (MT) and remains a clinical concern in acute ischemic stroke. This study investigated clinical predictors of FR in patients with middle cerebral artery (MCA) M2 occlusion. Methods:This single-center retrospective study included consecutive patients with acute cardioembolic stroke due to MCA M2 occlusion who underwent MT between April 2021 and December 2025. We included patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), and a pre-stroke modified Rankin Scale (mRS) score of 0-2. FR was defined as mRS 3-6 at discharge. We compared clinical, procedural, and outcome variables between patients with FR and those with effective recanalization (mRS 0-2). Multivariable logistic regression analysis adjusted for age and sex was performed to identify independent predictors of FR. A potential cutoff for receiver-operating characteristic (ROC) analysis was determined using the Youden index. Results:Participants comprised 30 patients (median age, 79 years; 56.7% men), with FR identified in 13 patients (43.3%). Patients in the FR group showed a higher baseline National Institutes of Health Stroke Scale (NIHSS) score than those in the effective recanalization group (median 19 vs. 10; p <0.01). In multivariable analysis, the NIHSS score was independently associated with FR (odds ratio, 1.18; 95% confidence interval, 1.01-1.39; p = 0.044). ROC analysis showed an area under the curve of 0.76, and an NIHSS score of 11 was identified as a potential cutoff for predicting FR. Procedural variables, including puncture-to-recanalization time, did not remain significant after adjustment. No significant differences in anatomical characteristics of M2 occlusion were observed between groups. Conclusion:A higher baseline NIHSS score may be associated with FR after MT in patients with MCA M2 occlusion. An NIHSS score of 11 may serve as a practical reference for risk stratification, although these findings should be considered exploratory. Baseline neurological severity may have a greater influence on clinical outcome than procedural factors after successful recanalization.
Objective: The optimal treatment strategy for acute ischemic stroke due to intracranial atherosclerotic disease (ICAD-AIS) has not been established. The Tigertriever (Rapid Medical, Yokneam, Israel) is a unique stent retriever (SR) that allows manual adjustment of radial expansion force, a feature that may be advantageous for the treatment of ICAD-AIS. We report a case of ICAD-AIS successfully treated with SR angioplasty using the Tigertriever. Case Presentation: A 71-year-old man developed sudden-onset left hemiplegia and was transported to our hospital 38 min after symptom onset. The National Institutes of Health Stroke Scale score was 13. MRA demonstrated occlusion of the right M1 segment of the middle cerebral artery (MCA), and diffusion-weighted imaging (DWI) showed faint hyperintensity in the posterior corona radiata. DSA revealed occlusion of the distal right M1 segment with good leptomeningeal collateral flow to the MCA territory. Given the patient's multiple atherosclerotic risk factors, the occlusion was clinically suspected to be associated with ICAD. After administration of aspirin (200 mg) and prasugrel (20 mg), SR angioplastywas performed using a Tigertriever 17. Postprocedural DSA demonstrated residual stenosis of approximately 50%; however, no recoil or re-occlusion was observed. The puncture-to-recanalization time was 23 min. Postprocedural DWI showed only a small hyperintense lesion in the right putamen, with no evidence of re-occlusion. The patient was discharged home on day 11 with a modified Rankin Scale (mRS) of 0. The post-procedure antiplatelet regimen was aspirin (100 mg) plus prasugrel (3.75 mg) for 1 month, followed by aspirin (100 mg) plus cilostazol (200 mg) until 6 months, and aspirin (100 mg) alone thereafter. During the 9-month follow-up, the mRS remained 0 without re-occlusion of the stenotic lesion. Conclusion: The Tigertriever may enable effective angioplasty for intracranial atherosclerotic stenotic lesions by allowing controlled adjustment of radial expansion force. This device may represent a promising therapeutic option for the treatment of ICAD-AIS.
Objective: The transfemoral approach is commonly used in neuroendovascular procedures. However, accesssite complications, although infrequent, can have serious clinical consequences. Acute limb ischemia (ALI) is a particularly serious condition, carrying a significant risk of limb loss and death and therefore requires rapid diagnosis and urgent management. Case Presentation: We report a rare case of acute external iliac artery occlusion due to a thromboembolism at the distal end of a femoral sheath after mechanical thrombectomy for acute ischemic stroke. During the procedure, reflux from both the guiding catheter and the femoral sheath disappeared, raising suspicion of an access-site complication; a contralateral femoral access angiography was performed. This evaluation revealed complete occlusion of the external iliac artery. Immediate thrombectomy was performed via a cutdown approach using a Fogarty arterial embolectomy catheter (Edwards Lifesciences, Irvine, CA, USA), resulting in the rapid restoration of arterial blood flow. The patient experienced neither limb ischemia nor neurological deterioration and achieved a favorable outcome. Conclusion: Thrombotic occlusion at the tip of a femoral sheath is a rare but potentially devastating complication of neuroendovascular procedures. The loss of reflux from a femoral sheath should alert clinicians to the possibility of access-vessel thrombosis and prompt immediate vascular evaluation and multidisciplinary intervention.
