BACKGROUND AND IMPORTANCE: Giant aneurysms can present technical challenges during treatment with flow diversion including inability to access the aneurysm outflow directly. Encircling the aneurysm with a microwire/microcatheter has been well described
however, it can result in a twisted stent because of catheter twisting during the reduction maneuver, which, in turn, could lead to thromboembolic complications. CASE PRESENTATION: Here, we describe a novel technique to manage the twist of the flow diverter in a giant internal carotid artery aneurysm using a combination of angioplasty and off-label placement of a balloon-mounted cardiac stent within the flow diverter. CONCLUSION: At 1 year, the aneurysm is completely occluded on digital subtraction angiography and MRI, and the patient is neurologically intact.