Introduction Flow diversion is a treatment option for large and giant anterior circulation aneurysms, however tortuosity can preclude the ability to use this therapy.
Case presentation A 59-year-old female presents with cavernous sinus syndrome of the right eye and a large cavernous carotid aneurysm. Just distal to the aneurysm were two 180° turns in the carotid artery. Attempts to navigate distal to the aneurysm with traditional 0.014′ microwires resulted in herniation of the microcatheters and wires into the aneurysm. Multiple attempts using various microwires, including a “buddy-wire” system failed to navigate and deliver the microcatheter to the carotid terminus. An 0.010′ microwire was navigated to the carotid terminus however did not offer enough support to navigate a microcatheter. A microvascular snare was navigated up the contralateral carotid and across the anterior communicating artery to the ipsilateral carotid artery. The microwire was ensnared at the carotid terminus, creating a rigid and supportive monorail (Abstract P-0016 figure 1). Over this system, a 0.026” microcatheter was navigated into position and two Pipeline devices were deployed across the neck of the aneurysm, successfully embolizing the aneurysm (Abstract P-0016 figure 2).
Discussion Treatment of large and giant aneurysms with flow divesion can be difficult due to tortuosity and the relative stiffness of the devices. By anchoring a microwire distally, a rigid monorail system can be created to deliver the catheters into position. The snare allows for entrapping and releasing the delivery devices as needed to complete the procedure.
Conclusion Challenging cases require utilization of devices that are outside normal indications, however within the capabilities of the devices. Knowledge of these technics can allow for treatment of otherwise untreatable vascular diseases.
Competing interests R Turner: Microvention, Codman. ev3, Penumbra, Mindframe. A Turk: None. I Chaudry: None. E Nyberg: None.
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