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Acute treatment of V4 aneurysm with flow diverter by retrograde approach

Authors: MAIA Carolina, VEIGA Ricardo, NUNES César, MACHADO Egídio

Discover the case of a 60-year-old female heavy smoker who presented with a sudden headache and subarachnoid hemorrhage from a V4 right vertebral artery aneurysm. Due to challenges with arterial catheterization, the medical team utilized a retrograde approach through the left radial access to perform endovascular treatment of the acute aneurysm.

Monday 15 May 2023
  • Case presentation

    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.




    • 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? 
  • Intervention


    • Pipeline Vantage 021 3.25x20
    • Satisfying position and apposition





    • 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.


  • Learning Points
    • 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.
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