Direct Carotid Puncture for Flow Diverter Stent Insertion

Objective: To report our experience of direct carotid
puncture and its use in the management of a large and rapidly expanding
cavernous aneurysm.

Methods: A patient with a cavernous aneurysm that
measured 25mm in maximum diameter underwent treatment with flow
diversion. The initial treatment strategy was parent vessel occlusion
however she failed the balloon occlusion test at 3 minutes. Due to
extremely tortuous vessels stable access via a common femoral artery
approach was impossible to achieve. We present our strategy, the
post-operative management and long term results.

Results: Using a direct carotid puncture three
telescoped Pipeline embolisation devices were successfully deployed
across the neck of the cavernous aneurysm without complication. The
puncture site formed a stable platelet plug after direct compression
with an ultrasound probe for 90 minutes with no post-operative
complications either intracranially or at the neck puncture site. At 2
year follow-up the aneurysm is completely excluded from the circulation.

Conclusion: Direct carotid puncture can be used as
access for intracranial interventional procedures even if patients are
on dual anti-platelet medication.