We performed a percutaneous carotid artery stenting (CAS) under ultrasonographic (US) guidance without contrast in patients with impaired renal function. We present the CAS procedure, which avoids the simultaneous use of fluoroscopy and US examination, to reduce radiation exposure.Methods: The carotid-stenotic lesion was marked on the skin of the neck based on preoperative US images. The distal protection balloon (DPB) was placed beyond the stenotic portion under fluoroscopy using magnetic resonance angiography and/or plain computed tomography images. The location of the DPB was confirmed by fluoroscopy. Subsequently, the DPB was expanded, and the carotid ultrasonography confirmed that blood flow was restricted. Thereafter, a stent was placed on the stenotic portion, and the dilatation of the artery was also confirmed by US imaging.Results: Among the six patients (mean age: 78.8 years) included in this study, three asymptomatic and three symptomatic cases were successfully treated using the US-guided CAS technique without complications. The operation time of this technique was similar to that of the conventional method. The average cumulative incident dose (CID) was 64.0 mGy (average CID value of the standard method: mGy).Conclusion: Percutaneous US-guided carotid stenting is useful for patients with carotid stenosis and impaired renal function. Avoiding the simultaneous use of fluoroscopy and ultrasonography can reduce radiation exposure for both technicians and patients.

BACKGROUNDIdiopathic dissecting cerebral aneurysms (IDCAs) are male dominant but are extremely rare in children. Many IDCAs in children are located in the posterior cerebral artery and the supraclinoid internal cervical artery. No cases of IDCA of the distal anterior cerebral artery (ACA) have been reported.OBSERVATIONSA previously healthy 7-month-old boy experienced afebrile seizures and presented at the authors’ hospital 1 week after the first seizure. He was not feeling well but had no neurological deficits. The authors diagnosed a ruptured aneurysm of the right distal ACA based on imaging results. He underwent emergency craniotomy to prevent re-rupture of the aneurysm. Using intraoperative indocyanine green videoangiography, the authors confirmed peripheral blood flow and then performed aneurysmectomy. Pathological examination of the aneurysm revealed a thickened intima, fragmentation of the internal elastic lamina, and a hematoma in the aneurysmal wall. The authors ultimately diagnosed IDCA because no cause was indicated, including a history of trauma. The boy recovered after surgery and was subsequently discharged with no complications.LESSONSThe authors reported, for the first time, IDCA of the distal ACA in an infant. The trapping technique is often used for giant fusiform aneurysms in infants. Indocyanine green videoangiography is useful for evaluating peripheral blood flow during trapping in this case.

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We report a rare case of a patient with a ruptured posterior communicating artery (P-com A) dissecting aneurysm and chronic kidney disease (CKD) treated by endovascular embolization using a small amount of contrast medium.Case Presentation: An 88-year-old female patient had sudden onset of headache and vomit due to subarachnoid hemorrhage. MRI revealed a ruptured dissecting aneurysm of the right P-com A. The patient had CKD of severity grade 4. Endovascular treatment was performed using only 10 mL of diluted contrast medium with injection through a microcatheter. The postoperative course was uneventful, and no deterioration of renal function occurred. Conclusion:With minimal amount of contrast medium, endovascular treatment could be safely and effectively performed for patients with P-com A dissecting aneurysms and severe CKD.