A 24-year-old man with a history of presyncopal episodes for 3 years, Ehlers–Danlos type IV, aortic dissection, gluteal artery pseudoaneurysm, possible platelet dysfunction with multiple spontaneous bleeding episodes, and chronic daily headache on sumatriptan presented after recurrent, unprovoked presyncopal episodes followed by chest tightness and headache. Given the patient's significant vascular and headache history, carotid and vertebral dissections were entertained as a possible etiology. Patient was stabilized, admitted, and advanced imaging was performed. Magnetic resonance imaging (MRI) of the brain and angiography (MRA) of the brain and neck were performed. MRI and MRA brain were unremarkable. MRA neck showed a right internal carotid artery (ICA) dissection with 50% stenosis, right vertebral artery (VA) dissection with 70% stenosis, and suspicion of left ICA dissection. Computed tomographic angiography (CTA) neck was performed to further evaluate. CTA redemonstrated the right ICA and VA dissections. Left ICA dissection was also noted with minimal luminal narrowing and a 2-mm proximal pseudoaneurysm []. Since this pseudoaneurysm was small and patient was at baseline, medical management and outpatient follow-up with neurointerventional surgery were recommended. He was placed on aspirin 81 mg daily at discharge. Anticoagulation was avoided as patient developed hemoptysis within 1 day of starting heparin drip during this admission, as well as having a history of bleeding events. Three-month posthospital follow-up with neurointerventional surgery was rather uneventful. However, CTA neck was repeated during this visit, which demonstrated a marked increase in size of the left ICA pseudoaneurysm – now 10 mm × 11 mm × 25 mm []. Digital subtraction angiography (DSA) confirmed this finding. Medical and surgical options were discussed with the patient. Due to the rapid increase in size of the pseudoaneurysm, the patient's genetic vascular comorbidity, and risk of rupture, it was felt to be in the patient's best interest to proceed with surgical intervention. Patient opted to undergo elective pipeline stenting of the pseudoaneurysm in lieu of medical management. Aspirin was continued and he was prescribed clopidogrel 75 mg daily to begin 1 week prior to stenting procedure. On the day prior to the procedure, P2Y12 assay was performed and indicated that the patient was an adequate responder to clopidogrel. During the stenting procedure, a 5-Fr micropuncture technique was utilized for femoral artery access. A 6-Fr introducer sheath was placed into the vessel and a 6-Fr Aeroflex catheter was introduced into the ascending aorta. A 4-Fr Berenstein catheter was then introduced into the guide catheter and, over a 0.038 Glidewire, the aeroflex catheter was introduced into the common and ICA. 3D images were obtained during angiography, which aided in stent selection. A Phenom 0.027 microcatheter was advanced across the pseudoaneurysm over a 0.014 Synchro 2 soft microwire. A 5.0-mm × 35-mm pipeline stent was then placed, followed by overlapping of a 5.0-mm × 25-mm variation. Postpipeline stent DSA indicated no intraluminal thrombus or luminal irregularities with good contrast filling and runoff through the stent []. Catheter was removed and femoral site was sealed with angioseal. Patient had no complications following procedure. He was at preoperative baseline on postoperative day 1 and was deemed stable for discharge. Discharge medications included aspirin 81 mg daily and clopidogrel 75 mg daily to prevent in-stent thrombosis. He was seen in follow-up 7 months after procedure. At that time, he noted that he stopped clopidogrel 3 months after procedure and was only taking aspirin currently, as per the recommended postoperative plan. Only complaint was fatigue. Examination revealed no neurological deficits. Follow-up DSA was performed at 7 months and showed near-complete resolution of the left ICA pseudoaneurysm [] with minimal contrast stasis in late arterial phase [].