As the use of the Pipeline Embolization Device (PED) for the treatment of complex intracranial aneurysms rises, knowledge about complications continues to accumulate amidt a paucity of reports on techniques and rescue strategies. We describe the case of a 70-year-old woman who presented with worsening reto-orbital left-sided pain and a large cavernous aneurysm. The patient underwent endovascular treatment with PED, and there was difficulty delivering the device due to significant vascular tortuosity. This resulted in poor PED deployment as the proximal end failed to open. Increasingly aggressive strategies were attempted to open the device, which resulted in an iatrogenic carotid cavernous fistula. We were finally able to rescue the device and open its proximal end with balloon inflation after using a contralateral trans-anterior communicating artery approach and crossing the PED in a retrograde fashion. Excessive vascular tortuosity poses a genuine risk of PED malfunction and poor deployment. Although we were able to rescue the device and our patient had no permanent morbidity, difficult vascular anatomy rendered the procedure extremely complicated with dreaded complications.
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