Modified carotid artery balloon angioplasty technique for challenging tandem occlusions in acute stroke

Tandem occlusion in the setting of acute ischemic stroke presents a challenge for endovascular thrombectomy, leading to delayed revascularization with associated poor prognosis and unfavorable outcomes. Simple angioplasty of the carotid stenosis does not always allow the guiding catheter to advance past the stenosis. We present a modified carotid angioplasty technique in which the guiding catheter can successfully be advanced through the carotid stenosis. This allows for faster recanalization and treatment of the intracranial occlusion, knowing that longer procedure times lead to worse outcome. During the modified angioplasty technique, the angioplasty balloon is positioned and inflated partially within the distal guiding catheter and partially within the carotid stenosis. This technique creates momentum for the guiding catheter to advance past the stenosis before it recollapses. Similar techniques have been described before to cross carotid stenosis with an aspiration catheter, and using a diagnostic catheter with a 0.035” wire, using the Dotter technique. However, with this technique it is the guide catheter which can be positioned beyond the proximal carotid stenosis, allowing for access to the intracranial circulation to perform as many thrombectomy passes as required. This allows for faster access to the occluded vessel, without the need for initial stenting, reducing the recanalization times in challenging tandem occlusion cases.