E-ISSN: 1019-5157
ISSN: 2651-5024
Technical Note
Brachial Access for Coil Embolization of a Ruptured Vertebral Artery–PICA Junction Aneurysm in a Patient with Complete Aortoiliac Occlusion and Subclavian Steal Physiology: A Technical Note
Ferhat CAN ,
Ahmed Yasin Yavuz ,
Cise Sahin ,
Sefa ÖZTÜRK✉
Neurosurgery, Haseki Training And Research Hospital,istanbul; Neurosurgery, Prof. Dr. Cemil Tascioglu City Hospital; Neurosurgery, Prof. Dr. Cemil Tascıoğlu City Hospital,istanbul; Neurosurgery, Istanbul University
Accepted: 27/10/2026
Article in Press
Corresponding Author:
Sefa ÖZTÜRK (sefa.ozturk@istanbul.edu.tr)
Abstract
Aim: To describe the selection and use of right brachial access for endovascular treatment of a ruptured posterior circulation aneurysm in a patient with multilevel vascular occlusion.
Materials and Methods: A 73-year-old woman presented with Hunt–Hess grade II and Fisher grade 3 subarachnoid hemorrhage caused by a 3.2-mm ruptured saccular aneurysm at the left V4 vertebral artery–posterior inferior cerebellar artery (PICA) junction. Bilateral transfemoral access attempts failed because of chronic complete aortoiliac occlusion with collateral reconstitution. Angiography also revealed complete left subclavian artery ostial occlusion and retrograde left vertebral artery flow toward the distal subclavian and axillary arteries, consistent with subclavian steal physiology. Given the unavailable femoral and left upper-extremity routes, right brachial access was selected to accommodate the planned 6-French system based on the patient’s vascular anatomy and procedural requirements. Transradial access was considered but not attempted.
Results: Balloon-assisted coil embolization achieved complete aneurysm occlusion (Raymond–Roy class I) while preserving the parent vertebral artery and PICA. No intraprocedural complications or clinically evident brachial access-site complications occurred during hospitalization or follow-up.
Conclusion: Early recognition of multilevel vascular occlusion is essential for selecting an alternative access route during emergency aneurysm treatment. Right brachial access may be a viable option in selected cases when transfemoral access is impossible and the anticipated support requirements favor this route over transradial access. This approach should remain individualized rather than be considered a routine first-line strategy.
Materials and Methods: A 73-year-old woman presented with Hunt–Hess grade II and Fisher grade 3 subarachnoid hemorrhage caused by a 3.2-mm ruptured saccular aneurysm at the left V4 vertebral artery–posterior inferior cerebellar artery (PICA) junction. Bilateral transfemoral access attempts failed because of chronic complete aortoiliac occlusion with collateral reconstitution. Angiography also revealed complete left subclavian artery ostial occlusion and retrograde left vertebral artery flow toward the distal subclavian and axillary arteries, consistent with subclavian steal physiology. Given the unavailable femoral and left upper-extremity routes, right brachial access was selected to accommodate the planned 6-French system based on the patient’s vascular anatomy and procedural requirements. Transradial access was considered but not attempted.
Results: Balloon-assisted coil embolization achieved complete aneurysm occlusion (Raymond–Roy class I) while preserving the parent vertebral artery and PICA. No intraprocedural complications or clinically evident brachial access-site complications occurred during hospitalization or follow-up.
Conclusion: Early recognition of multilevel vascular occlusion is essential for selecting an alternative access route during emergency aneurysm treatment. Right brachial access may be a viable option in selected cases when transfemoral access is impossible and the anticipated support requirements favor this route over transradial access. This approach should remain individualized rather than be considered a routine first-line strategy.
Keywords
Subarachnoid hemorrhage
Vertebral artery aneurysm
Posterior inferior cerebellar artery
Leriche syndrome
Subclavian steal
Neurointervention