Fig 1.

Algorithm of endovascular therapeutic strategies for tandem occlusions. The absence (n = 0) or presence (n = 1) condition the proximal treatment or not. The algorithm of the therapeutic decisions describes 2 strategies consisting of the treatment of, first, the proximal lesion (proximal occlusion strategy [POF]) or, first, the distal occlusion (distal occlusion first strategy [DOF]). The decision between the POF or DOF strategies is based on the following considerations raised during the endovascular procedure: 1) the ease of crossing the proximal occlusion site (easy crossing? difficult or impossible crossing?); 2) the patency and efficiency of the circle of Willis (efficient CoW or absence of CoW?); and 3) how threatening is the proximal atherosclerotic lesion? (unstable ulcerated plaque? moderate regular plaque?). In thrombus on ulcerated plaque, usually a single thromboaspiration allows easily crossing the proximal occlusion site and treating the distal (ie, intracranial) occlusion. In case of POF (a), the antiplatelet regimen consisted of the periprocedural intravenous administration of a unique loading dose of aspirin (250 mg) until the first imaging follow-up at 24 hours postoperatively. After ruling out any hemorrhagic transformation at 24 hours, a daily dual-antiplatelet therapy (160 mg of aspirin + 75 mg of clopidogrel) was instituted. In case of DOF (b), no anticoagulation or antiplatelet therapies were administered until the first imaging follow-up at 24 hours postoperatively. After we ruled out any hemorrhagic transformation at 24 hours, a daily monoantiplatelet therapy (160 mg of aspirin) was instituted. CoW indicates circle of Willis (efficient = 1; nonefficient or absent = 0); Prox. THREAT indicates any threatening of the proximal lesion (either atherosclerotic or dissecting).