Percutaneous direct carotid puncture using an elastic needle for coil embolization of a ruptured cerebral aneurysm with right-sided aortic arch and carotid stenosis: illustrative case.

backgroundEndovascular treatment of ruptured intracranial aneurysms can be particularly challenging in patients with a right-sided aortic arch and concomitant carotid artery stenosis, where stable catheterization via conventional transfemoral routes is often impossible. Direct carotid puncture is a potential alternative. However, conventional sheaths can transiently occlude the carotid artery and increase the risk of cerebral ischemia. OBSERVATIONS: An 87-year-old patient with subarachnoid hemorrhage due to a ruptured intracranial aneurysm presented with a right-sided aortic arch and severe calcified stenosis of the left common carotid artery. Given the tortuous and stenotic vascular anatomy, transfemoral access was discontinued. Percutaneous direct carotid puncture of the left common carotid artery was performed using an elastic needle with an outer diameter of 1.7 mm. This low-profile access allows microcatheter navigation and successful coil embolization without perioperative ischemic or hemorrhagic complications. Hemostasis was achieved using simple manual compression. LESSONS: When conventional endovascular access is precluded by complex vascular anatomy, particularly in cases complicated by carotid artery stenosis, direct carotid puncture using an elastic needle may offer a safer and less invasive alternative. This approach provides a feasible option in anatomically challenging situations in which standard sheaths would increase the risk of ischemic complications. https://thejns.org/doi/10.3171/CASE25869.