Establishment of an Optimal Access Route by Direct Carotid Artery Puncture

Abstract

We report a case of a ruptured basilar artery tip aneurysm in which the common carotid artery was occluded. The patent internal carotid artery distal to the occlusion was exposed via surgical cutdown and used as an access route, and endovascular treatment was performed using an adjunctive technique. An 88-year-old woman presented with subarachnoid hemorrhage caused by a ruptured basilar artery tip aneurysm, classified as WFNS Grade 2, for which endovascular treatment was performed. As it was a wide-neck aneurysm, an adjunctive technique was planned; however, both vertebral arteries showed severe wall irregularities, the right internal carotid artery had severe stenosis, and the left common carotid artery was occluded. Intracranial perfusion was primarily dependent on the posterior circulation. Due to concerns regarding widespread cerebral ischemia from cannulating both vertebral arteries, the patent left internal carotid artery was punctured directly. A microcatheter was guided to the right posterior communicating artery via the left posterior communicating artery, and horizontal stenting was performed, followed by intra-aneurysmal coil embolization. This case demonstrates that, even in challenging anatomical situations, an optimal access route can be established by thoroughly evaluating the vascular anatomy and considering direct puncture techniques.