Coil embolization for cerebral aneurysms of the vertebral basilar artery system includes trans-femoral, trans-brachial, and trans-radial approaches. However, these approaches are affected by stenosis or flexion of the proximal vertebral artery in many cases. In this study, we report the case of a patient in whom unilateral hypoplasia of the vertebral artery and marked cervical flexion on the contralateral side was used to treat a ruptured basilar aneurysm using the trans-femoral approach alone, combined with direct percutaneous puncture of the cervical vertebral artery.
A 73-year-old woman was hospitalized because of subarachnoid hemorrhage, and a broad-neck aneurysm was detected at the bifurcation between the posterior cerebral artery on the left side of the basilar artery and the superior cerebellar artery. The aneurysm was present at a high position, and the basilar artery was convoluted at the origin of the aneurysm, because of which clipping was difficult. We planned coil embolization with balloon remodeling technique or double catheters, but the left vertebral artery, primarily supplying the basilar artery, was markedly convoluted at 2 points in the cervical region, because of which inserting a parent catheter was difficult. As the right vertebral artery was extremely thin before the vertebrobasilar junction, there was no blood flow after the balloon was inserted for remodeling, and it was impossible to insert a microcatheter. The balloon was left in place, and the left cervical vertebral artery was percutaneously punctured distal to the site of convolution to insert a microcatheter. Embolization was performed using the balloon remodeling technique without any serious complication.
According to previous studies, the methods for direct percutaneous puncture of the cervical vertebral artery include: 1) changing the position after initially reaching the vertebral body, 2) using a roadmap, and 3) using an ultrasound-guided method. In terms of complications, hemorrhage at the puncture site, arterial dissociation, arteriovenous fistula formation, and aneurysm formation have been reported. Although this procedure is useful, it is technically difficult, and complications may develop. Therefore, it should be indicated for patients in whom all other methods are impossible.