PMC6744773_01
(a) 3D rotational angiography and digital subtraction angiography demonstrated a left vertebral artery dissecting aneurysm (10x13 mm in diameter). On 3D rotational angiography, a left vertebral artery dissecting aneurysm is located on the dominant side with no involvement of perforating arteries. (b) A 3D translucent road map view of the true barrel viewed position (B) and of the working position (C). (c) A 3D translucent road map view of the true barrel viewed position (B) and of the working position (C). (d and e) Deployment of the LVIS stent with "natural wire pushing." (f and g) The LVIS stent was placed with "tailor-made wall apposition at perforating arterial side" and coil embolization with "escaping doughnut-like form" in the true barrel viewed position. (h and i) Digital subtraction angiography after 3 months shows complete occlusion and maintenance of the parent circulation.
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F1
Follow-up MRA demonstrated that the VADA was getting bigger and stent-assisted coil embolization was planned for the preservation of the parent circulation. 3D rotational angiography (3DRA) revealed no remarkable perforating arteries involved in the VADA [Figure 1a]. Before treatment, a "true barrel viewed position and working position" was confirmed on 3DRA [Figure 1b and c]. The LVIS stent was back-loaded and deployed by unsheathing while withdrawing the microcatheter. The microcatheter was then pushed inside the LVIS stent through the inner delivery wire of the stent to expand the distal struts while being careful of "parent artery wall apposition at distal portion" and with moderate pushing, called, "natural wire pushing" [Figure 1d and e]. The LVIS stent was placed with "tailor-made wall apposition at perforating arterial side" in the barrel view, and coil embolization was performed with "escaping doughnut-like form" to prevent perforator infarcts [Figure 1f and g]. Follow-up MRA a day later and digital subtraction angiography (DSA) 3 months later showed complete occlusion of the aneurysms while the parent circulation remained intact [Figure 1h and i].
PMC6744773_02
(a and b) 3D rotational angiography and digital subtraction angiography demonstrated a left vertebral artery dissecting aneurysm (5.6x5.2 mm in diameter). On 3D rotational angiography, a left vertebral artery dissecting aneurysm located on the dominant side with involving the orifice of anterior spinal artery (arrow). (c) The LVIS stent was placed with "tailor-made wall apposition at perforating arterial side." Coil embolization was performed with "escaping doughnut-like form" in the true barrel viewed position. (d) Digital subtraction angiography after 3 months shows complete occlusion and maintenance of parent artery and anterior spinal artery circulation (arrowhead).
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F2
DSA revealed a VADA on the dominant side with involvement of the orifice of the ASA [Figure 2a and b]. Follow-up MRA after 1 day, 1 week, and 1 year and DSA after 3 months all showed complete occlusion of the aneurysm with maintenance of both parent artery and ASA patency [Figure 2c and d].
PMC6744773_03
(a and b) 3D rotational angiography and digital subtraction angiography demonstrated a right vertebral artery dissecting aneurysm (9.1x8.4 mm in diameter). On 3D rotational angiography, a right vertebral artery dissecting aneurysm located on the dominant side with involving the orifice of the posterior inferior cerebellar artery (arrow). (c) The LVIS stent was placed with "tailor-made wall apposition at perforating arterial side." Coil embolization was performed with "escaping doughnut-like form" in the true barrel viewed position. (d) Angiogram in the working position. Posterior inferior cerebellar artery patency is maintained (arrowhead).
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F3
A 66-year-old man showed enlarged left VADA involving the orifice of the PICA [Figure 3a and b]. We successfully performed endovascular treatment with the techniques described above [Figure 3c and d].