Prolapsing flow diverter stent in a giant aneurysm

Clinical background

• 30-year-old female patient
• left retro-orbital pain
• diplopia - horizontal, binocular
• examination- left 6^th nerve palsy, 3^rd, 4^th ,5^th cranial nerves normal, fundus - normal
• MRA - giant left paraclinoid aneurysm

Management

• angiography and FD stent
• equipment:
  • triple access - 6F sheath (ballast)
  • 6F guiding catheter (fargomax)
  • 021 microcatheter (phenome)
  • 014 microwire (traxcess)
  • flow diverter (pipeline with shield technology 4 x 30 mm)

Aortic arch

- anmolous arch
- right to left arteries - right CCA, left CCA, right subclavian, left subclavian
- right VA from right CCA

LT ICA LAO PRE

giant aneurysm, paraclinoid segment

25 mm x 15 mm with 15 mm neck bleb

RT CCA

Pre-procedure - towne                                         Cross compression, good cross flow

Microwire and microcatheter through the aneurysm

Pipeline with shielding technology 4 x 30 mm stent flow diverter partially deployed

FD stent bulging in aneurysm

FD stent prolapsed in aneurysm while retrieving wire

Foreshortened FD and straightening

Post foreshortening

Difficulty in passing the microwire through FD stent

Distal end of FD at Pcomm origin / Pcomm microwire navigation

Difficulty in entering ICA

Equipment:

• 6F guiding catheter (fargomax)
• 027 microcatheter (headway)
• 014 microwire (traxcess)

 

Advancement of the microcatheter, microwire through the FD stent

Advancing the microcatheter through the FD

Telescoping new FD stent
Fred FD - 4.5 x 45 mm

FD stents from the supraclinoid ICA (at the origin of Pcomm) to the straight segment of the petrous ICA

Post-procedure - left CCA - stasis in the aneurysm

VA left lateral and towne

• no deficit post-procedure
• uneventful hospital stay
• discharge - aspirin 75 mg daily, Ticagrelor 90 mg daily
• follow-up 3 months later- diplopia resolved, no headaches
• follow-up 11 months later - DSA
• clinically asymptomatic

Left lateral CCA - reduced size aneurysm, partially filled, FD stents in place

Left CCA towne