Left Transradial Neurointervention Using a 3-French Simmons Guiding Sheath for a Left Carotid Approach in Patients With an Aberrant Right Subclavian Artery: A Technical Note on a Case of Preoperative Embolization of Intracranial Meningioma

Abstract

An aberrant right subclavian artery (ARSA) is a rare variant of the normal aortic arch anatomy. Right transradial carotid artery cannulation is extremely challenging in patients with ARSA. Herein, we present a case of a right falcine meningioma with an ARSA that was successfully accessed with a 3-French Simmons guiding sheath via the left transradial approach. Additionally, preoperative embolization of the feeding middle meningeal artery (MMA) was performed. Here, we report our surgical technique. An 80-year-old woman was diagnosed with a right falcine meningioma with ARSA. The meningioma exhibited tumor staining in the parietal branch of the left MMA. We planned a preoperative MMA embolization via the left radial artery. After the 3-French Simmons guiding sheath was engaged in the left common carotid artery (CCA) using the pull-back technique, a triaxial system (3-French Simmons guiding sheath/3.2-French distal access catheter/microcatheter) was implemented. The 3-French guiding sheath to the left CCA was successfully achieved using the pull-back technique. Distal access catheter guidance to the proximal left MMA was successfully achieved without catheter kinking or systemic instability. However, guiding the microcatheter beyond the pterional segment of the left MMA parietal branch because of the severe curvature and tortuosity of the vessel was difficult. Thus, embolization with liquid and particulate embolic materials was abandoned, and tumor flow reduction was performed using coil embolization of the MMA. Three days after the neurointervention, craniotomy tumor removal was successfully performed achieving near-total resection of the tumor. Thereafter, no radial artery occlusion was observed at the puncture site. The patient was discharged from our hospital two weeks after craniotomy surgery. The left transradial artery approach using a 3-French Simmons guiding sheath is useful for left carotid artery cannulation in patients with ARSA.

Keywords: arterial lusoria; left radial access; meningioma; transradial neurointervention; tumor feeding embolization.

Figure 1. Preoperative MRI and angiography

a: Contrast-enhanced MRI displaying a right falcine meningioma with a maximum diameter of 40.1 mm. b: Aortic arch angiography through the catheter confirmed an ARSA (black arrows). c, d: Right common carotid artery angiography exhibiting no tumor staining (black circle) of the meningioma (b: early arterial phase and c: delayed arterial phase). e, f: Left common carotid artery angiography (d: early arterial phase, e: delayed arterial phase) demonstrating meningioma stain (black circle) through the middle meningeal artery parietal branch (black arrowheads). g: Aortic arch contrast computed tomography angiography revealing ARSA (white arrows). MRI, magnetic resonance imaging; ARSA, aberrant right subclavian artery.

Figure 2. The positioning and procedure for introducing the guiding sheath in an endovascular procedure

a: The left forearm placed in the sheath is fixed to the patient's lower abdomen in a position with minimal strain. b: Angiography is performed through the sheath of the left radial artery. c: The 3-French Simmons guiding sheath is introduced into the left common carotid artery using the pull-back technique.

Figure 3. Embolization procedure

a: Distal access catheter is guided to the left external carotid artery using the guidewire under roadmap guidance. Angiography, performed through the distal access catheter, demonstrates the meningioma stain (black arrow) through a middle meningeal artery parietal branch. In addition, curvature and tortuosity are detected in the pterional segment of the left MMA parietal branch. b: The distal access catheter is guided further distally to target the MMA temporal segment, along the axis of the microguidewire and the microcatheter. The black arrowhead represents the distal end of the distal access catheter. c: Angiography performed through the distal access catheter displaying the tumor stain (black circles). d: Coil embolization (white arrowhead) is performed. e: Postembolization left external carotid artery angiography revealing the disappearance of the tumor stain (black circle).

Figure 4. Postprocedural findings

a, b: Postembolization computed tomography scans revealed no complications, including epidural hematoma, and embolized coils (white arrow). c: Postoperative contrast magnetic resonance imaging displays nearly total resection of the meningioma. d: No left radial artery occlusion at the puncture site confirmed using ultrasound examination.