Tandem Lesions Due to Brachiocephalic Trunk Occlusions: What the Interventional Neuroradiologist Can Do

Tandem occlusions represent one of the most challenging scenarios in endovascular treatment of acute ischemic stroke.^1-4 Management of extracranial occlusion is technically demanding, especially when located at the level of the brachiocephalic trunk. We report 2 cases of tandem lesions due to a brachiocephalic trunk. In the first, a distal hemodynamic occlusion was treated with a side-by-side Wallstent (Boston Scientific), in the common carotid artery and subclavian artery, after unsuccessful thrombectomy using a double stent and a 0.88-inch-long sheath. In the second, a tandem lesion with M1 occlusion and stenosis at the origin of the brachiocephalic trunk was approached retrogradely to recanalize the M1, followed by a combined antegrade-retrograde strategy to treat the trunk. These cases illustrate the need for technical flexibility and adaptation, often requiring devices from peripheral or cardiology fields. Our experience underscores the importance of tailored endovascular strategies in managing complex extracranial occlusions associated with tandem lesions.