Stent-assisted coil embolization for an unruptured vertebral artery–posterior inferior cerebellar artery aneurysm with retrograde access via type 1 persistent primitive proatlantal artery: A case report

Abstract

Vertebral artery (VA)-posterior inferior cerebellar artery (PICA) aneurysms are rare lesions that are difficult to treat with both endovascular and surgical techniques. Tight angulation of the PICA from VA may make access to the PICA difficult from ipsilateral VA if adjunctive techniques are needed. Recently, the safety and efficacy of retrograde access have been reported. We report a case of endovascular treatment for a VA-PICA aneurysm with a stent-assisted technique using retrograde access via contralateral persistent primitive proatlantal artery (PPA). The patient was a 76-year-old woman with an unruptured VA-PICA aneurysm on the dominant VA side. Coil embolization with a stent-assisted technique using retrograde access seemed appropriate. However, the origin of the left VA was not confirmed. Left common carotid artery angiography demonstrated that the PPA (type 1) branching from external carotid artery joined the VA V4 segment. Retrograde access via the PPA for stenting was performed. A microcatheter for stenting was retrogradely advanced to the right PICA at ease. After deploying the stent, coil insertion was completed from the right VA, and the final angiogram showed adequate occlusion of the aneurysm with preservation of the PICA. Thus, PPA may be an approach route in the treatment of VA-PICA aneurysms with unconfirmed contralateral VA orifice and apparent PPA on angiography, when retrograde access is needed.

Vertebral artery transection with pseudoaneurysm and arteriovenous fistula requiring antegrade and retrograde embolization

“…Up and over retrograde access via the contralateral vertebral artery offers another method for addressing incomplete VAI treatment that avoids challenging and more invasive surgical reoperation. Reports of retrograde vertebral access exist for other indications, most often for vertebral or PICA aneurysms that cross midline or cannot be accessed ipsilaterally [15][16][17][18][19] for reasons including subclavian stenosis 19 . However, this technique has only rarely been applied in the setting of penetrating trauma 20,21 .…”

“…Retrograde vertebral access has been performed for other indications, most often for vertebral or posterior inferior cerebellar artery aneurysms that cross the midline or cannot be accessed ipsilaterally for reasons that include subclavian stenosis. 15 , 16 , 17 , 18 , 19 However, this technique has only rarely been applied in the setting of penetrating trauma. 20 , 21 Retrograde vertebral access can be especially useful for polytrauma patients who are too unstable for time-consuming, complex, open surgery.…”

Endovascular Therapy for an Aneurysm of a Distal Posterior Inferior Cerebellar Artery via the Ipsilateral Persistent Primitive Proatlantal Artery: A Case Report

“… 9) There have been reports of endovascular treatment of aneurysms via PPPA and stent-assisted coiling for VA–PICA aneurysm by placing a stent through the contralateral PPPA. 3 , 10) …”

“… 1 , 2) A previous study has reported finding a PPPA unintentionally during endovascular treatment and utilizing it as an access route. 3) …”

Our Experience in the Treatment of Vertebrobasilar Insufficiency Due to Cervical Spine Disorders

“…Unstable results of surgical treatment of VA stenosis are due to the lack of an optimal diagnostic algorithm to determine the nature, degree, and level of cervical spine disorders as the basis for the type of surgical intervention selection in critical vasoconstriction [5][6][7][8][9][10][11][12][13][14][15]. The system of indications for surgical treatment in tortuosity of segment VI of the VA and the issues of differentiated use of various techniques of reconstructive surgery and prediction of their results are insufficiently developed.…”