Acute reperfusion therapy via occluded vertebral artery using a guiding sheath for posterior circulation tandem occlusion: illustrative case

Vertebral artery (VA) size, anatomy, and occlusion status should be considered when selecting endovascular access for basilar artery mechanical thrombectomy. In a patient with concomitant basilar artery and VA occlusion and a patent but hypoplastic contralateral VA, the occluded VA should be selected. The authors report a technique that utilizes advancing a guiding sheath with attached dilator via an occluded VA.A 65-year-old male presented with disturbed consciousness because of an acute infarction of the brainstem and cerebellum caused by a basilar artery occlusion. Cerebral angiography showed a hypoplastic right VA and occlusion of the left VA at the origin. A regular wire was easily advanced through the occlusion and a 4-Fr diagnostic catheter was advanced into the distal left VA. A 6-Fr guiding sheath with attached dilator was placed in the left VA beyond the occlusion by exchanging it over a long wire. After removing the basilar artery thrombus, balloon angioplasty was performed at the left VA origin. Complete revascularization of the posterior circulation was achieved.A guiding sheath with dilator can advance across and dilate a VA occlusion at the origin to provide rapid access to the basilar artery.