Use of Direct Carotid Artery Puncture Access for Flow Diverter Embolization Combined with Coil Embolization: A Case Report

Objective: The fl ow diverter (FD) was developed as a new approach for treating aneurysms. However, FD embolization requires high technical skills and is challenging when the access to the aneurysm is diffi cult and when suffi cient force cannot be transmitted to the catheter because of severe vascular tortuosity. For FD embolization, when a transfemoral approach is too diffi cult, we perform direct puncture of the common carotid artery (CCA) under direct visualization by making a small incision. Herein, we report our experience using this approach. Case Presentation: We present a case of an 80-year-old woman with an unruptured aneurysm on the right internal carotid artery (ICA) treated by FD embolization in conjunction with coil embolization. We considered that access to the aneurysm would be challenging, with limited catheter maneuverability because of severe tortuosity of the bilateral femoral arteries and the region from the right CCA to the ICA. Thus, we decided to access the aneurysm by direct puncture of the right CCA. The aneurysm was easily accessed using this approach, and a stable procedure was completed by placing a sheath with a detachable hemostasis valve and then switching the hemostasis valve to a Y-connector on the sheath. As good catheter control was obtained despite the vascular tortuosity, the Pipeline Flex could be deployed and placed at the appropriate position. Conclusion: Direct puncture of the CCA under direct visualization for FD embolization is useful when access to the aneurysm is challenging and when catheter maneuverability decreases because of severe tortuosity.