Deep inspiration-facilitated stenting for extremely tortuous vertebral artery ostium in a Type III arch

Endovascular treatment of vertebral artery ostial (VAO) stenosis can be technically challenging in the presence of severe supra-aortic tortuosity, particularly a Type III aortic arch where stable guide catheter positioning is often difficult to maintain. During device delivery, inadequate proximal support may result in guide catheter prolapse into the aortic arch, compromising procedural success. Although adjunctive support techniques such as the buddy-wire technique may improve system stability, extreme vascular tortuosity can still impede the advancement of balloons or stents.1 A deep inspiration maneuver with transient breath-holding may facilitate device delivery by inducing caudal displacement of the aortic arch and proximal subclavian artery.2 Because the distal vertebral artery remains relatively fixed within the transverse foramina, this maneuver generates temporary axial tension across the V1 segment, partially straightening the tortuous vascular course and improving device trackability.3This technical video (video 1) demonstrates step-by-step endovascular reconstruction of an extremely tortuous right VAO lesion in a patient with prior failed stenting caused by hostile vascular anatomy and subsequent recurrent stenosis. Despite the Type III arch anatomy, a transfemoral approach was mandated over a radial approach due to the acute ostial geometry, providing the necessary antegrade delivery vector. We highlight a dual strategy approach combining distal wire-anchor support to enhance guiding stability and respiratory-induced vascular straightening to facilitate device navigation, ultimately enabling precise stent deployment and complete revascularization.neurintsurg;jnis-2026-025713v1/V1F1V1Video 1.