AComA Crossover Treatment of a Complex ICA Tip Aneurysm Using pEGASUS HPC stent

A 32-year-old man presented with intense headache, vertigo, and diplopia; imaging showed a left pre-PICA V3–V4 vertebral artery dissection with severe stenosis causing posterior fossa ischemia.

Moreover, there are three right-sided aneurysms at the ICA tip, PComA, and AChA. 

PRE TREAT DSA

POST-TREAT DSA

 

PRE TREAT DSA

Poll #1

Poll#2

The decision was made to treat with coils AChA and cover two aneurysms (PComA, AChA) with P64 4x21 mm.

POST-TREAT DSA

Poll #3

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Why standard treatment was difficult

1. Unfavorable ipsilateral angle for stent delivery
2. Multiple aneurysms already treated in the same vascular territory

Management

 

• Double femoral access
• Left ICA → AComA → pEGASUS HPC delivery
• Right ICA → coil microcatheter
• Simultaneous dual microcatheter strategy.
• This approach allowed reconstruction across the target segment and controlled aneurysm occlusion with preservation of the parent vessel.

Excelsior SL-10 trans AComA

 

pEGASUS HPC 3.5 mm x 20 mm

Excelsior SL-10 via R-ICA

 

Double femoral access (Triaxial System). Cross over from L-ICA (AcomA) - w/ Excelsior 10 for Pegasus 3.5x20 and Exclesior 10 for coiling from R-ICA

6 MONTHS FU DSA

6 MONTHS FU MRI

• Patent parent vessel
• No in-stent stenosis
• Stable aneurysm occlusion
• No new ischemic lesions

Conclusion

Cross-circulation through the AComA can provide an elegant reconstructive option for complex ICA bifurcation aneurysms when direct ipsilateral access is suboptimal.

In this case, pEGASUS HPC enabled stable stent-assisted coiling with durable angiographic results at 6 months.”

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