Kouhei Nii

Fukuoka University, Hukuoka, Fukuoka, Japan

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Publications (33)37.8 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Carotid in-stent thrombosis can cause thromboembolic events although it is a rare complication of carotid artery stenting(CAS). We present a successful case of percutaneous mechanical thrombectomy for symptomatic subacute in-stent thrombosis. A 64-year-old man was hospitalized for the treatment of a cerebral infarction presenting with dysarthria and left upper extremity weakness. Following sufficient medical management including dual anti-platelet therapy, CAS was performed because cerebral angiograms showed severe and long-segment right internal carotid artery(ICA)stenosis. Although the stenosis was resolved, right cerebral infarction presented with progressive left hemiparesis 12 days after CAS. Emergency cerebral angiograms revealed right ICA occlusion due to in-stent thrombosis. Rapid revascularization with percutaneous mechanical thrombectomy of the in-stent occlusion was performed using the Penumbra Aspiration System because a microguidewire could not pass through the occlusion. Post-procedural angiogram revealed recanalization of the right ICA, and the patient was free from neurological events after the last procedure. The evaluation and treatment of peri-procedural in-stent thrombosis following CAS must be prompt and aggressive for prevention of catastrophic events. Percutaneous mechanical thrombectomy is a useful tool for rapid treatment of acute or subacute in-stent thrombosis after CAS.
    No shinkei geka. Neurological surgery 09/2013; 41(9):785-9. · 0.13 Impact Factor
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    ABSTRACT: Stent-assisted coil embolization is effective for intracranial aneurysms, especially wide-necked aneurysms; however, the optimal antiplatelet regimens for ischemic events that develop after coil embolization have not yet been established. We aimed to determine the onset time of such postoperative ischemic events and the relationship between these events and antiplatelet therapy. We performed coil embolization using a vascular reconstruction stent for 43 cases of intracranial aneurysms and evaluated the incidence of postoperative ischemic events in these cases. Nine patients showed postoperative ischemic events during the follow-up period (13 ± 7 months). Two patients developed cerebral infarction within 24 hours. Five patients developed transient ischemic attack within 40 days while they were receiving dual antiplatelet therapy. In addition, 1 patient showed cerebral infarction 143 days postoperatively during single antiplatelet therapy, and a case of transient visual disturbance was reported 191 days postoperatively (49 days after antiplatelet therapy had been discontinued). We increased the number of antiplatelet agents in 4 of these patients. The other 5 patients were under strict observation with dual antiplatelet therapy. All these patients were shifted to single antiplatelet therapy 3-13 months postoperatively. No recurrence of ischemic events was noted. Postoperative ischemic events are most likely to occur within 40 days postoperatively. For patients with postoperative ischemic events, additional ischemic events can be prevented by increasing the number of antiplatelet agents; subsequently, they can be shifted to single antiplatelet therapy after the risk of recurrence has decreased.
    Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 08/2013;
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    ABSTRACT: The pull-through angioplasty technique allows stable wire tension and stabilization of the device during the procedure. In this technique, a guide wire is passed from one sheath to another, usually with the aid of a snare device. We describe the treatment of occlusive subclavian artery disease and lesion at the origin of the vertebral artery employing a brachiofemoral pull-through technique without using a snare device. In this technique, the guide wire is advanced from the femoral artery to the brachial artery. The guide wire is directly inserted into the sheath placed at the brachial artery. The brachial artery is compressed proximal to the point of sheath insertion to prevent bleeding. The sheath is extracted temporally and the guide wire is caught outside of the body. The sheath is then introduced again through the guide wire. We used the pull-through technique without a snare device in seven cases, and we were able to build the pull-through system in six of these cases without a snare device. This pull-through technique without a snare device is not difficult to use, and may reduce the time and cost of angioplasty procedures.
    Interventional Neuroradiology 06/2013; 19(2):167-72. · 0.77 Impact Factor
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    ABSTRACT: The clinical effects of two different types of antiplatelet drugs, cilostazol and thienopyridine drugs, were compared in patients treated by carotid artery stenting (CAS). Two hundred patients scheduled for CAS were randomized to either cilostazol or a thienopyridine drug (ticlopidine or clopidogrel). The study was conducted in open-label design. Aspirin was also given to all patients. All episodes of periprocedural hemodynamic instability (bradycardia, hypotension) were recorded together with all instances of stroke, cardiac morbidity, and death within 30 days of the procedure. Angiographic follow-up studies were conducted about 6 months after CAS. Finally, 197 patients were enrolled in this study; 97 were treated with cilostazol (cilostazol group) and 100 with a thienopyridine drug (thienopyridine group). In the 30-day follow-up period, the incidence of stroke, cardiac adverse effects, and death was not significantly different between the 2 groups (cilostazol group 7.2%, thienopyridine group 11.0%; p = 0.85). The incidence of intra- and postprocedural bradycardia was significantly lower in the cilostazol group (cilostazol group 18.6% and 2.1%, thienopyridine group 40.0% and 18.0%, respectively; p < 0.01). Although the incidence of intraprocedural hypotension did not significantly differ between the 2 groups, postprocedural hypotension was significantly lower in the cilostazol group (16.5% vs. 34.0%, p < 0.01). In-stent restenosis on follow-up angiograms was lower in the cilostazol group but not significantly (0% vs. 4.4%, p = 0.12). This small open-label study shows that cilostazol may reduce periprocedural bradycardia and hypotension compared with thienopyridine drugs in patients treated by CAS.
    Neurologia medico-chirurgica 01/2013; 53(3):163-70. · 0.49 Impact Factor
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    ABSTRACT: An 87-year-old man presented with extracranial vertebral artery (VA) occlusion and progressive vertebrobasilar ischemia despite maximal medical management. Cerebral angiography showed left proximal VA occlusion, termination of the right VA at the ipsilateral posterior inferior cerebellar artery, and hypoplastic bilateral posterior communicating arteries. Although the stump of the left VA ostium was not visualized, the distal patent artery was reconstituted via muscular branches from the left subclavian artery (SCA). Endovascular angioplasty with a stent for left VA occlusion was performed. The non-visualized VA ostium was extrapolated from the computed tomography angiography findings of the distal patent VA and the partial calcification of the SCA. The occluded VA was penetrated by the guide wire and revascularized by balloon angioplasty with the stent using the support of a snare wire inserted via the left brachial artery for stabilization of the guide catheter. This treatment resulted in resolution of the severe neurological findings.
    Neurologia medico-chirurgica 01/2013; 53(6):422-426. · 0.49 Impact Factor
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    ABSTRACT: PURPOSE: This retrospective study aimed to compare the effectiveness of the embolization prevention mechanism of two types of embolic protection device (EPD)-a distal protection balloon (DPB) and a distal protection filter (DPF). METHODS: Subjects were 164 patients scheduled to undergo carotid artery stenting: a DPB was used in 82 cases (DPB group) from April 2007 until June 2010, and a DPF was used in 82 cases (DPF group) from July 2010 to July 2011. Rates of positive findings on postoperative diffusion-weighted imaging (DWI) and stroke incidence were compared. RESULTS: Positive postoperative DWI results were found in 34 cases in the DPB group (41.4 %), but in only 22 cases in the DPF group (26.8 %), and there was only a small significant difference within the DPF group. In the DPB group, there was one case of transient ischemic attack (TIA) (1.2 %) and four cases of brain infarction (2 minor strokes, 2 major strokes; 4.9 %), compared to the DFP group with one case of TIA (1.2 %) and no cases of minor or major strokes. CONCLUSIONS: In this study, significantly lower rates of occurrence of DWI ischemic lesions and intraoperative embolization were associated with use of the DPF compared to the DPB.
    Japanese journal of radiology 11/2012; · 0.73 Impact Factor
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    ABSTRACT: Hyperperfusion syndrome (HPS) is a rare but severe complication after carotid artery stenting (CAS). Reliable methods for predicting HPS remain to be developed. We aimed to establish a predictive value of hemorrhagic HPS after CAS. Our retrospective study included 136 consecutive patients who had undergone CAS. We determined the cerebral circulation time (CCT) by measuring the interval between the point of maximal opacification of the terminal portion of the internal carotid artery and the cortical vein. We calculated intraprocedural CCT changes (ΔCCT) by subtracting postprocedural CCT values from preprocedural CCT values. The mean ΔCCT was 0.9 ± 0.9 seconds; 3 patients (2.2%) with prolonged ΔCCT (2.7, 5.4, and 5.8 seconds) developed HPS. The cutoff time of 2.7 seconds predicted hemorrhagic HPS retrospectively with 100% sensitivity and 99% specificity. Our findings suggest that post-CAS HPS can be predicted by using the ΔCCT value obtained by intraprocedural digital subtraction angiography. Patients with a ΔCCT >2.7 seconds require careful intensive hemodynamic and neurologic monitoring after CAS.
    Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 12/2011;
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    ABSTRACT: Selection of the appropriate diameter of stent is difficult in patients with the size mismatch between the internal carotid artery (ICA) and the common carotid artery (CCA). Although stent overexpansion (SOE) in the ICA after carotid artery stenting (CAS) is suspected of producing restenosis, SOE has not been well established. We discuss its incidence, predictors, and outcomes. We retrospectively reviewed follow-up angiographs of 206 CAS-treated arteries in 201 patients who had undergone CAS. SOE was defined as angiographic evidence of an intimal gap between the non-stented normal and the dilated stented ICA at the distal stent edge. We also collected data on the patients' clinical status, comorbidities, and radiological and procedural data. Patients with SOE were further followed up closely by duplex ultrasound scans. SOE was detected in nine of 206 CAS-treated ICAs (4.4%). Univariate analysis revealed a significant association between SOE and open-cell stents, the stent diameter (p < 0.01), pre-procedural stenosis, the ICA diameter, ICA/CCA ratio, and the ICA/stent ratio (p < 0.05). Entering these variables into a logistic regression model, open-cell stents were the only variable that significantly increased the risk for SOE (OR 2.36; 95% CI 0.99-4.60; p < 0.05). During a mean clinical follow-up of 31.1 months (range 24-39 months), none of the patients with SOE developed new neurologic ischemic symptoms, stent-edge stenosis, or in-stent restenosis. SOE after CAS was not associated with clinical adverse effects. This study suggests that the diameter of stent should be determined by reference to the CCA diameter without respect to the ICA diameter.
    Neuroradiology 07/2011; 54(5):481-6. · 2.70 Impact Factor
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    ABSTRACT: The difference between coil-embolized ruptured and unruptured aneurysms with respect to intra-aneurysmal thrombus formation remains to be determined. We examined whether there was a difference between ruptured and unruptured coil-embolized aneurysms in the rate and timing of thrombus formation in the aneurysmal sac and discuss the effect of thrombus on the treatment outcome. We evaluated 209 aneurysms with an aneurysmal dome smaller than 10 mm and a neck size less than 4 mm. Of these, 91 (43.5%) were ruptured. We assessed intra-aneurysmal thrombus formation by the coil-packing ratio (CPR): the percentage of coil volume occupying the aneurysmal sac. The initial CPR was defined as the CPR at which contrast influx into the sac ceased and the final CPR as that at the end of the procedure. ΔCPR was calculated as the difference between initial and final CPRs. Embolized aneurysms were evaluated on follow-up angiograms. The initial CPR was significantly lower in ruptured aneurysms (P < .01), and there was not a significant difference in the final CPR between ruptured and unruptured aneurysms (P = .05). ΔCPR was significantly higher in ruptured aneurysms (P < .01). The rate of aneurysmal recanalization was significantly higher in ruptured aneurysms (P < .05). The incidence of recanalization was high in ruptured aneurysms with low initial CPR and ΔCPR values. In ruptured aneurysms, intra-aneurysmal thrombus formation tends to occur in the earlier stages of coil embolization. In some cases, thrombus formation may inhibit dense coil packing and result in recanalization.
    Neurosurgery 04/2011; 69(3):651-8; discussion 658. · 2.53 Impact Factor
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    ABSTRACT: Three women older than 75 years presented with spontaneous superficial temporal artery (STA) pseudoaneurysms manifesting as a pulsatile mass in the preauricular region. None of the patients had a history of trauma. Histological examination of the surgically removed masses identified pseudoaneurysms based on the presence of connective tissue and adventitia. Spontaneous STA pseudoaneurysms are extremely rare. We suggest that all 3 aneurysms were associated with latent dissection and external force exerted by the frames of glasses.
    Neurologia medico-chirurgica 01/2011; 51(10):713-5. · 0.49 Impact Factor
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    ABSTRACT: The rates of hemodynamic depression (HD) and thromboembolism were compared in 95 carotid artery stenting (CAS) procedures performed in 87 patients with severe carotid artery stenosis using self-expandable braided Elgiloy stents (Wallstent) in 52 and slotted-tube Nitinol stents (Precise) in 43 procedures. The blood pressure, pulse rate, and neurological signs were recorded at short intervals during and after CAS. All patients underwent diffusion-weighted magnetic resonance imaging within 5 days after the procedure. The incidences of hypotension, bradycardia, and both were 17.9%, 3.2%, and 11.6%, respectively. The rate of postprocedural HD was 23.1% with Wallstent and 44.2% with Precise; the difference was significant (p = 0.025). No patient manifested major cardiovascular disease after CAS. Diffusion-weighted magnetic resonance imaging revealed thromboembolism after 26.9% and 34.9% of Wallstent and Precise stent placement procedures, respectively; the difference was not significant. The type of self-expandable stent placed may affect the risk of procedural HD in patients undergoing CAS. Postprocedural HD was resolved successfully by the administration of vasopressors and by withholding antihypertensive agents.
    Neurologia medico-chirurgica 01/2011; 51(8):556-60. · 0.49 Impact Factor
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    ABSTRACT: Changes in the cerebral blood flow (CBF) are important for planning postoperative care in patients treated by carotid artery stenting (CAS). The relationship between intraprocedural changes in the angiographic cerebral circulation time (CCT) and perioperative CBF changes were retrospectively studied in 49 CAS procedures performed in 46 patients with carotid artery stenosis. The CCT, defined as the interval between the timing of maximal opacification at the terminal portion of the internal carotid artery and at the cortical vein, was determined by referring to time-density curves of data obtained from routine intraprocedural digital subtraction angiography. The intraoperative change in CCT (Delta CCT) was calculated for each of the 49 procedures. CBF studies, using dynamic perfusion computed tomography, were performed 10-2 days before and 2-4 days after CAS. Perioperative changes in the ratio of the CBF in the territory of the middle cerebral artery on the affected side to CBF on the contralateral side (%CBF) were calculated by subtracting pre- from postoperative %CBF (Delta%CBF) and the correlation between Delta CCT and Delta%CBF was evaluated. Mean CCT was shortened by 1.1 seconds from 5.3 to 4.2 seconds after CAS. Mean %CBF increased by 11.9% from 91.8% to 103.7% after the procedure. Delta CCT and Delta%CBF showed a significant positive correlation (r = 0.61, p = 0.008). Intraprocedural changes in angiographic CCT are predictive of postoperative CBF in patients with CAS.
    Neurologia medico-chirurgica 01/2010; 50(4):269-74. · 0.49 Impact Factor
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    ABSTRACT: A 62-year-old man experienced transient episodes of vertigo associated with left upper extremity weakness. Cerebral angiography showed 75% right internal carotid artery (ICA) stenosis and divergence of a persistent primitive hypoglossal artery (PPHA) distal to the stenosis. The area of stenosis was at a high position and he had a past medical history of congestive heart failure, which contraindicated carotid endarterectomy (CEA). Therefore, carotid artery stenting (CAS) was performed with single distal balloon protection. The stenotic area was restored and he was discharged without suffering recurrent attacks. CAS may be an effective alternative treatment to CEA to prevent further ischemic attacks in the posterior circulation in patients with PPHA. CAS using simple embolic protection devices is possible if the distance between the distal end of the ICA stenosis and the origin of the PPHA is sufficiently long.
    Neurologia medico-chirurgica 01/2010; 50(10):921-4. · 0.49 Impact Factor
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    ABSTRACT: We assessed the morphological change of calcified plaque after carotid artery stenting (CAS) in vessels with heavily calcified circumferential lesions and discuss the possible mechanisms of stent expansion in these lesions. We performed 18 CAS procedures in 16 patients with severe carotid artery stenosis accompanied by plaque calcification involving more than 75% of the vessel circumference. All patients underwent multidetector-row computed tomography (MDCT) to evaluate lesion calcification before and within 3 months after intervention. The angiographic outcome immediately after CAS and follow-up angiographs obtained 6 months post-CAS were examined. The preoperative mean arc of the calcifications was 320.1 +/- 24.5 degrees (range 278-360 degrees ). In all lesions, CAS procedures were successfully carried out; excellent dilation with residual stenosis <or=30% was achieved in all lesions. Post-CAS MDCT demonstrated multiple fragmentations of the calcifications in 17 of 18 lesions (94.4%), but only cracks in the calcified plaque without fragmentation in one (5.6%). Angiographic study performed approximately 6 months post-CAS detected severe restenosis in one lesion (5.6%) without fragmentation of calcified plaque. Excellent stent expansion may be achieved and maintained in heavily calcified circumferential carotid lesions by disruption and fragmentation of the calcified plaques.
    Neuroradiology 12/2009; 52(9):831-6. · 2.70 Impact Factor
  • Brain and nerve = Shinkei kenkyū no shinpo 09/2008; 60(8):970-1.
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    ABSTRACT: Because of its high complication rate, the endovascular treatment (EVT) of anterior communicating artery (ACoA) aneurysms less than 3 mm in maximum diameter remains controversial. We evaluated EVT of tiny ruptured ACoA aneurysms with Guglielmi detachable coils (GDCs). We treated 19 ruptured ACoA aneurysms with a maximum diameter of <or=3 mm with GDCs. The pretreatment Hunt and Hess score was grade 1 in four patients, grade 2 in six, grade 3 in six, and grade 4 in three. The patients were clinically assessed before and after treatment and with multiple angiographic follow-up studies. All EVTs were successful; there were no aneurysm perforations or any other treatment-related complications. In five patients older than 80 years the transfemoral approach was difficult, and the direct carotid approach was used. Complete and near-complete occlusion was achieved in 16 patients (84.2%) and 3 patients (15.8%), respectively. Of the 19 patients, 16 (84.2%) were followed angiographically for a median of 38.5 months (range 16-72 months). None demonstrated recanalization of the aneurysm requiring additional treatment. In 15 patients (78.9%) the final outcome was good (modified Rankin scale, mRS, score 0-2), and 3 patients (15.8%) died or suffered severe disability (mRS score 4-6). None of 18 patients who were followed clinically for a median of 39.5 months (range 17-84 months) experienced rebleeding. Even tiny ruptured ACoA aneurysms can be safely treated by EVT by expert neurointerventionalists using advanced techniques.
    Neuroradiology 07/2008; 50(6):509-15. · 2.70 Impact Factor
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    ABSTRACT: Changes in the location and length of the Wallstent RP during carotid artery stenting (CAS) were evaluated using intraoperative videos of 28 patients with carotid artery stenosis who underwent CAS with a 10/20 mm Wallstent RP to determine the appropriate stent placement. The stent was deployed after its midpoint was positioned over a virtual center line, the perpendicular line which crossed the most stenotic point of the lesion on the road mapping image. The length of the stenotic lesion, the changes in the locations of the distal and proximal ends of the stent, and the changes in stent length were examined. The distal end of the stent moved a maximum of 6.1 mm toward the proximal side to a point 19.9 mm from the virtual center line. The proximal end moved a maximum of 11.3 mm toward the distal side to a point 14.7 mm from the virtual center line. The stent length ranged from 37.7 to 44.5 mm (mean 41.2 mm). The 10/20 mm Wallstent RP placed by our technique covers the entire lesion with no less than 5.7 mm of margin over the segment distal to the lesion in patients with stenotic segments shorter than 29.4 mm.
    Neurologia medico-chirurgica 07/2008; 48(6):249-52; discussion 252-3. · 0.49 Impact Factor
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    ABSTRACT: A 50-year-old man presented with a symptomatic aneurysm arising from the right inferior cavernous sinus artery (ICSA) associated with a cerebral arteriovenous malformation (AVM) manifesting as a 3-month history of progressive right abducens nerve palsy. Cerebral angiography demonstrated a high-flow AVM and a saccular aneurysm arising from the right ICSA acting as a meningeal feeder. The symptom was thought to be attributable to aneurysmal mass effect rather than the AVM. The aneurysm was successfully treated with endovascular embolization and the symptom improved gradually. Hemodynamic stress in the ICSA may have resulted in the development of the aneurysm of the ICSA. Meningeal artery aneurysm presenting with cranial nerve palsy is extremely uncommon. The present case illustrates the need for detailed evaluation of the external carotid artery and internal carotid artery vasculature in patients with cerebral AVMs.
    Neurologia medico-chirurgica 07/2008; 48(6):257-8. · 0.49 Impact Factor
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    ABSTRACT: An 82-year-old man with an asymptomatic left high-grade carotid stenosis was treated with carotid artery stenting (CAS) under distal protection. The procedure consisted with predilation with a 5 x 40 mm percutaneous transluminal angioplasty (PTA) balloon, deployment of a 10 x 20 mm self-expandable stent, post-dilation with a 7 x 20 mm PTA balloon, and aspiration of debris with 60 ml of blood. The cervical carotid angiogram immediately after deflation of the distal blocking balloon demonstrated a small in-stent filling defect of the contrast medium that protruded from the anterior wall of the carotid artery. The following cranial carotid angiogram showed abrupt occlusion of the left middle cerebral artery (MCA). Because the in-stent lesion had vanished in the repeat study after recognition of this embolic event, it was suggested that an embolus had been liberated from the in-stent lesion, reaching the left MCA and obliterating it. In this case, the embolus was speculated to originate in the ruptured plaque, which protruded into the stent through the cells of the device and became liberated into the bloodstream. Attention should be paid so as not to overlook any plaque protrusion, which may be seen subsequently as a cerebral embolism on the angiogram obtained immediately after CAS.
    Radiation Medicine 06/2008; 26(5):318-23.
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    ABSTRACT: Our aim was to assess the feasibility of carotid artery stent placement (CAS) for calcified lesions. Using embolic protection devices (EPDs), we performed 51 CAS procedures in 43 patients with severe carotid artery stenosis accompanied by plaque calcification. Before intervention, all lesions were subjected to multidetector-row CT. The arc of the circumferential plaque calcification was measured on axial source images at the site of maximal luminal stenosis, and the total volume of the plaque calcification was determined. The angiographic outcome immediately after CAS, and intra- and postoperative complications were recorded. The mean arc of calcification was 201.1 +/- 72.3 degrees (range, 76-352 degrees ), and the mean of the total calcification volume was 154.9 +/- 35.4 mm(3) (range, 92-2680 mm(3)). Balloon rupture occurred in 1 procedure (2.0%) at predilation angioplasty; all 51 CAS procedures were successful without clinical adverse effects. Although there was a correlation between the arc of plaque calcification and residual stenosis (r = 0.6, P < .001), excellent dilation with residual stenosis < or =30% was achieved in all lesions. There was no correlation between the total volume of calcification and residual stenosis. None of the patients developed stroke or death within 30 days of the CAS procedure. CAS by using EPDs to treat lesions with plaque calcification is feasible even in patients with near-total circumferential plaque calcification.
    American Journal of Neuroradiology 05/2008; 29(8):1590-3. · 3.17 Impact Factor