Treatment for Giant Fusiform Aneurysm Located in the Cavernous Segment of the Internal Carotid Artery Using the Pipeline Embolization Device
A 40-year-old woman presented with a 5-year history of sharp left facial pain and discomfort of the left orbit when she moved her eye. Digital subtraction angiography (DSA) revealed a giant fusiform aneurysm involving the cavernous segment of the left internal carotid artery (ICA) (). The aneurysm was measured by 25×11 mm. The A1 segment of the anterior cerebral artery of the left ICA was nondominant. A cross filling test with manual compression of the left ICA showed a lack of blood supply from the anterior communicating and posterior communicating arteries. As a result, a balloon occlusion test was not indicated. Because of the size, fusiform shape and poor-collateral blood supply of the aneurysm, we decided to treat the patient with a PED. The patient received 100 mg of aspirin and 75 mg of clopidogrel per day for 1 week before the procedure.\nAfter starting general anesthesia, the patient was given a bolus of heparin and activated clotting time was maintained at 2 to 3 times baseline throughout the procedure. After accessing the right femoral artery, a 6 Fr Envoy guiding catheter (Cordis, Miami, FL, USA) was placed just proximal to the petrous segment of the left ICA using a coaxial technique. We gained control angiography to measure the size of the aneurysm and the parent arteries. The diameter of the inflow vessel at the petrous segment was 4.1 mm and the diameter of the outflow vessel at the cavernous segment was 3.2 mm. A Marksman microcatheter (EV3, Irvine, CA, USA) with a 0.027-inch diameter was introduced at the M1-M2 junction. A 4.0×20 mm PED was delivered via microcatheter. The PED was deployed across the targeted landing zone by repeated maneuvers of microcatheter unsheathing, delivery-wire stabilization and advancement, and microcatheter loading. Postprocedural angiography demonstrated that filling of the aneurysmal sac was slower than observed by preprocedural angiography. DynaCT and three-dimensional reconstructive angiography showed good stent position with no redundant portions between the PED and the wall of the parent vessel (). The periprocedural course was uneventful. The patient's facial pain was markedly improved the day after the procedure and the patient was discharged.\nThe patient returned for a 3-month follow-up angiography, having maintained antiplatelet medication of 100 mg aspirin and 75 mg clopidogrel per day. Symptoms had gradually reduced without neurological changes. DSA demonstrated anatomic reconstruction of the parent artery with complete occlusion of the aneurysm (). The distal portion of the PED covered the origin of the meningohypophyseal trunk; however, the meningohypophysial trunk was easily visualized by angiography. DynaCT and three-dimensional reconstruction angiography showed proper patency of the in-stent lumen without stenosis. The PED remained in the same position without migration or change in shape.