Figure 2.

Illustration of the “Distal-to-proximal” strategy for the posterior tandem occlusion through the occluded dominant vertebral artery (dirty-road path). (A) A guiding catheter was placed at the subclavian artery. After the microguidewire passed through the occluded segment, a balloon (3 mm diameter) was introduced to dilate the stenotic segment. (B-C) The guiding catheter was advanced to the V2 segment through the stenotic segment over the partially inflated balloon. Aspiration was performed first to remove residual thrombus. Then basilar artery thrombectomy was performed with a stent retriever, contact aspiration, or a combination of stent retriever with aspiration. (D) After successful revascularization of the basilar artery, the microguidewire was sent to the V2 segment, and the guiding catheter was pulled back with gentle aspiration to remove all possible residual intraarterial thrombi. (E) A balloon-expandable stent or a self-expendable stent was then implanted at the ostial vertebral artery over the microguidewire.