Complex anterior communicating artery (ACoA) aneurysm treatment with two kissing Pipeline™ Vantage with Shield technology and RIST™ radial system

Authors: Rodríguez Paz Carlos Manuel, Rojas Jiménez Ana María

Using radial access for multiple interventions during one procedure.

• Case presentation

  Patient situation

  Woman with incidental finding of three aneurysms on examination for stroke. mRS 1. Klippel-Trénaunay.

  • 57-year-old patient
  • Non-ruptured incidental aneurysms: ACoA 9 mm and 3 mm right ICA. PHASES score 8 and 1 respectively. The difficulty of treatment is due to the exit of the A2 segments from the aneurysmal sac. The reconstruction of the arteries with flow diverters is the most appropriate in our opinion.

   

  Preparation for the intervention

  Seven days before, double antiplatelet therapy was prescribed and started with a loading dose of 300 mg of clopidogrel, followed by 75 mg and 100 mg of acetylsalicylic acid every 24 hours. Platelet aggregation test was not performed.

   

  

  Volume rendering of the magnetic resonance angiographic sequence. Wide neck aneurysm in Anterior Communicating artery.

  

  Volume rendering of rotational angiography. Cavernous aneurysm. Lateral visualization.

  

  Volume rendering of rotational angiography. Cavernous aneurysm. Anterior-Posterior visualization.

• Intervention

  Treatment chosen

  Second time treatment of ACoA aneurysm. Flow-diverting stent placement was planned. Previously the left side A1-A2 was stented (PipelineTM Vantage). In this step, the right side is treated with an A1-A2 stent (Pipeline™ Vantage). Distal radial access was chosen to minimize puncture complications (the same in both procedures). An ipsilateral internal carotid artery (ICA) has been treated in this procedure by embolization with coils.

   

  Intervention

  • General anesthesia
  • Ultrasound-guided puncture of the distal radial artery (dTRA) in the right anatomical snuffbox.
  • Short 23 cm 7F sheath was placed and 3,000 IU of heparin and 100 micrograms of nitroglycerin were administered.
  • The right internal carotid artery was selectively catheterized with a combination of a 95 cm guiding catheter (RIST™) and 2 X Simmons selective catheters. The distal part of the guiding catheter was positioned in the distal extracranial internal carotid.
  • A three-dimensional angiography was acquired for simulation and selection of the flow-diverting stent to be implanted. Pipeline™ Vantage 2,5x16.

   

  

  Simulation of the placement of the stent with Sim & Cure software

  

  Simulation of the placement of the stent with Sim & Cure software.

   

  • Stent deployment was performed with:
    • 0,058 intracraneal catheter (Sofia™ EX)
    • 0,021 microcatheter (Phenom™ 21 - compatible with selected device)
    • 0,014 micro guidewire (Traxcess™)
  • *Tip: To achieve the catheterization of the right A2 segment, it was necessary to make a loop in the aneurysm sac with the micro guidewire and the microcatheter. To undo this loop, we use an anchor with a 3x20 Solitaire™ stent retriever.
  • To treat the carotid aneurysm:
    • 0.017 microcatheter (Headway™ Duo)
    • 3x8 coil (Axium™ Prime 3D Frame) 

   

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• Results

  Adequate deployment of the stent. Good apposition. Procedure ends without complications. Good evolution during admission. Discharge 48 hours after the procedure.

  • The stent was deployed in the desired position with correct apposition to the walls.
  • No complications were demonstrated in the control series.
  • The patient was discharged in 48 hours.

   

  

  Obliquus angiography post-treatment of the aneurysm. The stent A1-A2 is permeable, and the flow is slow in the aneurysm sac. The cavernous aneurysm is excluded with the expected packaging simulated with the software.

   

  This case is sponsored by Medtronic.

   

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