Embolization of VBJ fenestration aneurysm

Patient presentation

• 67-year-old male construction worker with Rt arm claudication
• CTA neck: Rt Proximal Subclavian artery occlusion

• Incidentally, VBJ fenestration Bi-Lobed aneurysm ~ 13 mm

Treatment decision

• CCA/ Axillary bypass: Symptomatic relief, ability to sacrifice Rt vertebral without jeopardizing Rt SC flow
• Flow diversion at the inferior aspect of the fenestration on the left
• Avoid coverage, if possible, of the AICAs (No Rt PICA and dominant left AICA) and ASA.
• Sacrificing the right vertebral along with the aneurysm and Rt arm of fenestration

Treatment plan

Intervention

Embolization

• Access:
  • Left vert(femoral A.):
    • Ballast
    • 6 Fr Sofia
    • Headway 27
    • Fred X 4X13
  • Rt vert( radial A.):
    • 6 Fr Benchmark
    • Excelsior l 10
    • HYDROFRAME Coils
• Alternatives in US:
  • Pipeline
  • Surpass Evolve

• The right arm of fenestration became more obvious after partial deployment of stent due to straightening of VBJ
• Given wide neck and to avoid thromboembolic events, decision was to continue to occlude the right vert with aneurysm and fenestration.

Stent deployment