Right-sided paraophthalmic aneurysm treated with a Pipeline™ Vantage Shield using RIST™ Radial access System

CASE PRESENTATION

• Previously healthy 66-year-old female patient.
• MRI was performed due to TGA symptoms.
• Incidental right paraophthalmic internal carotid artery aneurysm discovered.
• MIP reconstruction of a 3D rotational DSA demonstrated a laterally and cranially projecting wide-necked aneurysm.
• The 3D image showed that the ophtalmic artery orifice (arrow) is not engaged in the aneurysm neck.

TREATMENT STRATEGY

• This is one of our first Vantage & RIST™ cases.
• Very easy handling with the RIST™ system already from the beginning.
• Right radial puncture was performed in ultrasound guidance.
• Short Terumo Slender 7F sheath inserted.
• Rist™ 5 Fr Sim2 130 cm select catheter was telescoped inside a 079 Rist™ 100 cm guide catheter over a 0.035 Terumo wire.
• After reforming the Simmons curve of the Rist™ catheter in the aorta, the proximal right CCA was easily catheterized.

• Terumo wire was advanced into the distal petrous ICA while keeping the select catheter hooked at the CCA origin.
• The Rist™ guide catheter was advanced over the Terumo wire to the petrous ICA.
• Before removing the select catheter, the DSA images were taken.
• Here are the AP and lateral runs before the procedure. 

• Distal end of the 079 Rist™ guide catheter is marked with a red arrow.

• FD sizing was performed on the basis of measurements of the artery, acquired from the 3D rotational angiography data.
• In addition to manual measurements, virtual sizing with the Sim&Size® simulation was performed.
• Pipeline™ Vantage Shield 4 x 16 mm device was chosen.
• The simulation showed that both distal and proximal ends would land on a straight vessel segment.
• The patient had started with Prasugrel 5 mg and aspirin 100 mg 5 days before the procedure.
• Platelet function was evaluated by Multiplate Analyzer (Roche Diagnostics, Mannheim, Germany) before the procedure.
• During the procedure, activated clotting time (ACT) was doubled by administering a heparin bolus and ACT controlled at 30 – 45 minutes intervals. After the procedure, heparinization was neither antagonized nor maintained.
• Prasugrel and aspirin continued for at least 3 months, until the first DSA-control.

• The distal part of the Vantage was already nicely opposed to the vessel wall. Aneurysm neck was covered as well.
• We opened the mid-proximal part of Vantage in the curve. Some tension is constructed in order to open the device properly.
• An intermediate catheter would probably have smoothened the opening.
• After this case, we have always used an intermediate catheter-like Navien 058.

• Arrow is pointing to the ”point of no return” in the beginning of the video.

• First fluoroscopy was run to show the proximal opening and another fluoroscopy was run to show how smoothly the 027 Phenom microcatheter was advanced through the device after opening it. 

• These images were captured from the final run after the procedure.
• The wall apposition was achieved nicely.
• There was no contrast stagnation in the aneurysm yet.
• The patient was discharged the next day in good clinical condition. 

RESULTS

• Here we have the 3-month DSA follow-up. The aneurysm is still filling with contrast, but there is remarkable stagnation now visible and almost no intima hyperplasia. 
• The patient continues with aspirin only and we will do a new DSA in three months
• The DSA control was done via radial access of course.

This case is sponsored by Medtronic.