Introduction Anterior communicating artery (ACOM) blister aneurysms are rare and pose a significant challenge for treatment using either endovascular or microsurgical techniques with associated high morbidity and mortality. Flow diversion is the usual mainstay of endovascular treatment however ACOM aneurysms may continue to fill after unilateral ACA pipeline embolization. We describe a case of bilateral ACA pipeline embolization using H‐construct for a ruptured ACOM blister aneurysm with off label use of the new fourth generation Pipeline Vantage with Shield Technology device. Materials and methods Pubmed search of case reports/series. Results A 84‐year‐old male with history of hypertension, right MCA stroke, CKD presented with HH1, F3 SAH mostly affecting sylvian cisterns. Initial cerebral angiogram was unremarkable. 4 days later patient had neurological decline with repeat CT head showing worsening subarachnoid hemorrhage and right frontal intraparenchymal hemorrhage. He underwent emergent EVD placement and repeat cerebral angiogram showed ACOM blister aneurysm at right A1‐A2 junction. Multidisciplinary treatment options were discussed and flow diversion was offered. Because of presence of codominant bilateral ACA A1 segments, due to flow dynamics and in order to achieve durable occlusion of ACOM aneurysm, H‐construct pipeline embolization was planned. DAPT was started 48 hours post ventriculostomy. Radial access was obtained using 6F slender sheath system. Coaxial system of 6F RIST guide catheter over 5F SOFIA intermediate catheter over Phenom 21 microcatheter and Aristotle 18 microwire was navigated into right ACA and Pipeline Vantage 2.5x14 mm device was deployed from right A2 to A1 segment. Similarly, Pipeline Vantage 2.75x12 mm device was deployed from left A2 to A1 segment with good apposition. Post operatively patient's exam stabilized without any further episodes of SAH/IPH. Control angiogram performed 1 week later showed remodeling of the aneurysm blister morphology and significant contrast stasis with OKM grade B2 occlusion status and devices remained patent. Patient was eventually discharged after prolonged hospital course due to multiple medical comorbidities. Conclusions Some ACOM aneurysms may persist after unilateral ACA flow diversion. H‐construct flow diversion helps to achieve complete aneurysm occlusion. Pipeline Vantage appears to offer improvement in delivery, visibility, distal opening, ease of deployment, as well as recapture compared to its predecessors, making above complicated procedures quicker and safer. image
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