Zenith devices used in this case:

Patient Information

• Male, 64 years old
• Intermittent numbness and weakness in the right limbs for 2 years
• Muscle strength of all four limbs 5/5; negative pathological signs
• NIHSS scores: 0

Preoperative Angiography

CTP: Hypoperfusion in the left frontal, parietal, and temporal lobes

MRI: Chronic encephalomalacia in the left corona radiata and centrum semiovale

DSA (from outside hospital): Severe stenosis of the left ICA C7 segment with an associated aneurysm

Surgical Challenges

1. The severe stenosis with aneurysmal dilation at the left ICA PCom segment poses a dilemma. If the stenosis is treated first (balloon angioplasty + stenting), aneurysm rupture may occur due to traction during balloon expansion.
2. If the aneurysm is treated first and rupture occurs, the proximal stenosis may compromise coil embolization and increase the risk of cerebral infarction.
3. Regardless of technique (stent-assisted coiling or flow diverter), the proximal stenosis must be addressed with balloon angioplasty. Balloon angioplasty is thus a necessary step either way:

• Given the likely pathogenesis (post-stenotic dilatation), the aneurysm (3.2 × 2.1 mm, regular morphology) has a low spontaneous rupture risk
• Resolving the stenosis may reduce hemodynamic stress and rupture risk

Treatment Strategy

1. As the patient's symptoms suggest recurrent TIAs with high risk of stroke, priority is given to resolving the stenosis • Drug-eluting balloon-expandable stent considered over flow diverter due to poor support in bony segments • Given low rupture risk, balloon-expandable stent is favored for one-step resolution.
2. Emergency plan: If aneurysm ruptures intraoperatively, immediately neutralize heparin and perform coil embolization; treat the stenosis afterward.

Devices

• 6F 90cm Long Sheath
• 6F 115cm Zenith Distal Access Catheter
• 014inch 2m Micro Guidewire
• 014inch 3m Micro Guidewire
• 5mm*12mm Intracranial Drug-eluting Stent

Procedure

A long sheath and Zenith Distal Access Catheter were used to establish the pathway. DSA confirmed severe stenosis of the left ICA PCom segment with aneurysmal dilation.

A short micro-guidewire and microcatheter were advanced to the distal M1 segment to confirm intraluminal positioning. The microwire was exchanged for a longer micro-guidewire, positioned in the M2 segment.

Using an exchange technique, the microcatheter was withdrawn and the micro guidewire fixed. A sirolimus-eluting stent was delivered to the stenotic segment. The balloon was inflated via pressure pump, and the stent deployed.

Post-deployment angiography showed significant improvement of the stenosis. Follow-up angiography revealed that the presumed aneurysm was actually an infundibulum at the origin of the posterior communicating artery, requiring no further intervention.

Postoperative Angiography

Postoperative CT showed no hemorrhage and minor contrast retention.

Surgeon's Notes

• The Zenith Distal Access Catheter provided excellent trackability and proximal support for stable access.
• The final diagnosis (infundibulum rather than aneurysm) became evident only after stenosis resolution. This validated the preoperative strategy: prioritizing stenosis treatment effectively resolved the TIA/stroke risk and avoided overtreatment.

Surgeon Information

Bifeng Zhu, Hao Tian and Yue Wan, The Third People's Hospital of Hubei Province