Pipeline Embolization of Giant Cavernous Internal Carotid Artery Aneurysm with Direct Carotid Puncture and Arteriotomy Closure Device: Neuroendovascular Surgical Video

Flow diversion technology has revolutionized the treatment of complex anterior circulation cerebral aneurysms. However, vessel tortuosity and atherosclerotic disease may hamper the standard transfemoral access used in these procedures. Percutaneous direct carotid puncture is a viable alternative, but adequate carotid closure must be achieved. Here, we present the first case of a giant partially thrombosed aneurysm of the cavernous internal carotid artery treated with a Pipeline embolization device (PED; ev3 Neurovascular, Irvine, California, USA) via direct carotid puncture. A 79-year-old female presented with bilateral giant cavernous internal carotid artery aneurysms. She was successfully treated with PED on the right side and failed treatment with PED on the left side using a transfemoral approach due to common carotid artery tortuosity. She was lost to follow-up but presented 3 years later with worsening left eye pain and ophthalmoplegia. Percutaneous direct carotid puncture was performed under ultrasound guidance, and a 6-French sheath was inserted. Using roadmap guidance, a Marksman microcatheter (ev3 Neurovascular) with the support of a Navien intermediate catheter (ev3 Neurovascular) was advanced into the left middle cerebral artery, and 4 PEDs were deployed within the paraclinoid and cavernous segments of the internal carotid artery to completely cover the neck of the aneurysm. Carotid closure was performed for the first time with a Mynx collagen plug device (AccessClosure, Inc., Mountain View, California, USA). The patient recovered from the procedure without any complications, and her ophthalmoplegia partially improved. Informed patient consent for the procedure and for publication was obtained (Video 1).