Retrograde trans-posterior communicating artery rescue balloon angioplasty of incompletely expanded pipeline embolization device: complication management

Background: Pipeline embolization device (PED) deployment is a technically demanding procedure. Incomplete device expansion or deployment is one intra-operative risk, especially in patients with significant vascular tortuosity. Case description: We describe the case of a 71-year female with an unruptured left vertebral artery saccular aneurysm. Tortuosity of the arteries proximal to the aneurysm complicated deployment and the proximal end of the PED failed to expand despite several maneuvers. The inadequately expanded PED caused flow limitation in the left vertebral artery and it became imperative to achieve wall apposition of the PED. We salvaged the PED from the left vertebral artery by retrograde trans-right posterior communicating artery balloon angioplasty. Conclusions: Our case documents the successful application of the rarely used salvage strategy–anterior-to-posterior circulation retrograde rescue balloon angioplasty of an unopened PED.