Acute treatment of V4 aneurysm with flow diverter by retrograde approach

Patient presentation

• 60-year-old female patient;
• Heavy smoker;
• No previous medical history;
• Presented with a sudden headache and subarachnoid hemorrhage secondary to a V4 right vertebral artery aneurysm.

CASE

• Patient was taken to DSA but we could not catheterize both femoral and right subclavian arteries.
• Thoraco-abdominopelvic CTA for therapeutic planning confirmed occlusion of these arteries (arrows) with the left subclavian artery patent.

• EV treatment of the acute aneurysm by retrograde approach through left vertebral artery by left radial access.

Treatments options:

• Stent & coils? 
• Flow Diversion (FD)? 
• Vertebral occlusion? 

Treatment

• Pipeline Vantage 021 3.25x20
• Satisfying position and apposition

Outcome

• No intraprocedural complications seen;
• Patient Recovered well and discharged after 6 days;
• On Follow up:
  • No neurological deficits (mRS 0)
  • No cerebral infarction
  • No embolism
• Last CTA revealed patency of FD with aneurysm exclusion and filiform right distal V4 segment.

• Complex problems sometimes require an alternative approach;
• Radial approach provides new options to the interventionist in challenging situation;
• Flow diversion is an attractive alternative strategy for management of acutely ruptured aneurysms.