Transarterial coil and ONYX embolization for delayed rupture of a large cavernous internal carotid aneurysm after flow diverter treatment: A case report

Abstract

ObjectivesWe present an innovative method of transarterial trans-cell coil and ONYX (Medtronic, Minneapolis, MN, USA) for bailout of delayed rupture, resulting in a direct cavernous carotid fistula (d-CCF) after flow diverter (FD) treatment for a large cavernous internal carotid artery aneurysm. Case presentationsA 72-year-old male patient who underwent FD implantation with the Pipeline Flex (Medtronic) for an aneurysm of this location measuring 15 mm in diameter. He developed a sudden-onset headache and pulsatile tinnitus on postoperative day 7 due to delayed rupture of the aneurysm, resulting in a high-flow d-CCF. The transarterial trans-cell approach was achieved by selecting a combination of several types of microcatheters and micro-guidewires, along with the development of an access system. Despite the use of extensive coil embolization for the aneurysm, the d-CCF persisted. To address this, liquid embolization utilizing ONYX was conducted, resulting in complete occlusion of the d-CCF. Furthermore, during a follow-up examination three months later, complete occlusion of the aneurysm was observed due to the effect of the FD. ConclusionsTransvenous embolization (TVE) or parent artery occlusion (PAO) has been reported as the rescue treatment of choice for delayed rupture of such an aneurysm following FD implantation; however, TVE may not always result in complete cure with a single treatment, while PAO carries the risk of potential ischemic complications. An alternative option, transarterial trans-cell embolization using a combination of coil and ONYX, has proven to be effective, although it has some limitations.