Single-stage hybrid management of severe carotid stenosis and unruptured intracranial aneurysms using direct transcarotid access: Illustrative case

Background: The coexistence of symptomatic extracranial internal carotid artery stenosis (ICAS) and unruptured intracranial aneurysms (UIAs) is an uncommon but clinically challenging condition for which there is no standardized treatment strategy. The optimal treatment sequence remains controversial because carotid revascularization may theoretically alter intracranial hemodynamics, whereas endovascular treatment through a critically stenotic carotid artery presents significant technical challenges. Hybrid approaches may provide an alternative for carefully selected patients. Case Description: A 74-year-old man with severe multilevel cervicocerebral stenosis disease characterized by complete right internal carotid artery (ICA) occlusion with posterior-to-anterior collateralization and critical left ICAS, severe left vertebral artery stenosis with collateral recruitment, and two UIAs: an anterior communicating (ACom) aneurysm and a Posterior communicating artery (PCom) wide-necked aneurysm, underwent multidisciplinary evaluation following coronary revascularization and dual antiplatelet therapy. Considering the severely compromised collateral reserve, the technical limitations of transfemoral navigation across a heavily calcified stenosis, and the potential risks associated with staged procedures, a single-stage hybrid strategy was selected. Through direct surgical exposure and puncture of the left ICA distal to the stenotic segment, the ACom aneurysm was treated with a Woven EndoBridge, and the wide-necked aneurysm with a flow diverter, followed immediately by carotid endarterectomy (CEA). Conclusion: This illustrative case demonstrates that individualized single-stage hybrid management using direct carotid access, endovascular aneurysm treatment, and CEA may represent a feasible option in highly selected patients when conventional staged strategies or transfemoral access are technically unfavorable. Careful multidisciplinary planning and tailored treatment sequencing are essential in these complex neurovascular scenarios.