Stent-graft delivery across a highly tortuous proper hepatic artery using balloon anchoring, an inner dilator, and partial unsheathing.

Proper hepatic artery aneurysms are a subset of visceral artery aneurysms. Due to the risk of rupture, treatment is recommended for aneurysms of the proper hepatic artery measuring ≥ 20 mm in diameter. To preserve hepatic blood flow, treatment consisting of autologous graft interposition, vascular bypass surgery, or stent-graft placement is recommended for such aneurysms. Here, we report the case of a man in his 70s with concurrent aneurysms of the proper hepatic artery, right gastric artery, and right gastroepiploic artery. He had severe pulmonary emphysema, which precluded general anesthesia, making him ineligible for surgical intervention. Therefore, we planned coil embolization of the right gastric and right gastroepiploic artery aneurysms and stent-graft placement for the proper hepatic artery aneurysm. Vessel tortuosity was marked, with a tortuosity index of 1.67, which was higher than that previously reported; therefore, stent-graft deployment was anticipated to be extremely challenging. In highly tortuous vessels, vessel straightening can produce an accordion-like appearance with step-like deformities, thereby impeding stent-graft advancement. Using a balloon-anchoring technique and an inner dilator, we successfully advanced the guiding sheath to a position distal to the aneurysm, achieving successful placement of the stent-graft. There were no periprocedural complications, and the stent-graft remained patent at the 3-month follow-up. Antiplatelet therapy is ongoing. These techniques may represent a viable approach for stent-graft insertion into highly tortuous vessels.