Transcarotid access for the treatment of recurrent, previously ruptured wide necked bifurcation aneurysm with the WEB device: A technical video

The Woven Endobridge (WEB) device is an FDA-approved intrasaccular flow disruptor to treat most intracranial wide-necked bifurcation aneurysms. ¹ Based on the rising experience with safe and effective results, it has been increasingly utilized for the treatment of residual and recurrent aneurysms.^2,3 Additionally, the device has been reported as an off-label treatment option for Posterior communicating (Pcom) artery aneurysms with optimal morphology. ⁴ A transfemoral or transradial artery access is conventionally utilized for WEB embolization.^1–3 In this technical video, we share our experience with the use of direct carotid puncture to perform WEB embolization for a large recurrent Pcom aneurysm in an elderly female with a history of subarachnoid hemorrhage that was initially treated with surgical clipping. A direct puncture of the left common carotid artery (CCA) under ultrasound guidance was performed after failed attempts to select the left ICA via both transfemoral and transradial access due to type 3 aortic arch and extreme tortuosity of the proximal left CCA. The aneurysm was successfully treated with a 5 mm × 2 mm WEB SL device. There are limited studies of transcarotid access for neurointerventional procedures including mechanical thrombectomy, intracranial stent placement etc.^5,6 To the best of our knowledge, this technical video represents the first documented report of WEB embolization via transcarotid access. We aim to highlight the feasibility of transcarotid arterial access for WEB embolization as an effective bailout strategy. In addition, the nuances of direct carotid puncture along with possible complications, and potential management strategies have been discussed.