Pipeline Embolization Device Insertion Using a Direct Exposure Transcarotid Approach

Objective: To increase procedure-related options for Pipeline Embolization Device (PED) insertion.Case Presentation: An 83-year-old female patient with a right internal carotid artery (ICA) cerebral aneurysm in the cavernous sinus being on follow-up showed subsequently an increase in the aneurysmal size and diplopia, and surgery was considered. Diagnostic cerebral angiography showed marked arteriosclerosis, and it was difficult to guide selectively a catheter into the ICA. Therefore, for treatment, we planned PED insertion by direct puncture of the carotid artery through direct cervical surgical exposure. Under general anesthesia, a cervical skin incision exposed the common carotid artery. Surgical vessel holding tapes were placed distal and proximal to the site to be punctured on the common carotid artery. Using a pediatric puncture kit, a 4 Fr sheath was inserted in the common carotid artery. Next, under fluoroscopy the ICA was entered using a 0.035-inch guidewire that was exchanged for a 6 Fr Destination 90-cm (Terumo Corporation, Tokyo, Japan) long. This was carefully guided into the ICA. Subsequently, a PED measuring 5 × 35 mm was inserted to the aneurysmal site using a 5 Fr Navien 115 cm (Marksman; Covidien, Irvine, CA, USA). Hemostasis by suture was performed at the site of arterial puncture. There were no intraoperative or postoperative complications.Conclusion: Direct puncture of the carotid artery can be an effective method for patients in whom it may be difficult to insert a PED due to arteriosclerosis.