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.

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.