Ipsilateral Transradial Approach For Management Of Ruptured Vertebro-basilar Junction Aneurysm In A Case Of Subclavian Steal Syndrome

Patient

• 66 Year female with Grade 1 SAH
• CT Angiography demonstrated  vertebro-basilar junction aneurysm
• Vitals stable on day of ictus with GCS- E4V5M6
• BP- 130/40, PR- 90/min, RR- 18/min
• Saturation-99%

NCCT Head

CTA

• Patient Taken for Transfemoral Diagnostic DSA

Aortic run taken due to inability to catheterize Innominate artery

Delayed Aortic Run

Delayed Aortic Run

Selective LVA run

LICA Run

• Ruptured aneurysm
• Occluded Innominate artery
• Right subclavian steal with flow maintained through left vertebral artery
• Tight loop in the proximal left Vertebral artery
• Financial Contraint

Possible interventions

• Flow divertor/Stent assisted coiling using Trans femoral approach è Risk in acute settings with requirement of dual antiplatelets, obliteration of the flow into the Right VA, Tight loop in the left VA
• Balloon assisted/ Simple coiling using Transfemoral approach èTight loop in left VA with potential risk of injury when Guiding catheter is placed, Thromboembolic risks with Balloon, technical challenges
• Right radial approach with simple coiling

Post Procedure CT

• No Intraprocedure complications seen
• Patient Recovered well and discharged after 6 Days
• Right radial artery patent at Discharge
• M6 Status, No Deficits
• On Follow Up

Learning Points

• Complex problems sometimes require a simplified alternative approach
• Radial approach provides new options to the interventionist in challenging situations
• Simple coiling always provide better peace of mind to the operator in acute settings.
• Ipsilateral radial approach is feasible in subclavian steal without the risk of RAO