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.