Transcirculatory Approach for the Treatment of Multivessel Occlusions

Acute ischemic stroke (AIS) with multivessel occlusions (MVOs) is a rare but devastating condition involving more than one territory in the ipsilateral or bilateral anterior circulation or anterior plus posterior circulation. Multiple territory ischemia would result in more severe neurological deficits due to larger infarcts. Reduction of leptomeningeal collateral circulation by one or more concomitant distal emboli from the primary occlusion site may explain the worse outcome despite successful and rapid reperfusion. In endovascular treatment of patients with MVO, it is difficult to prioritize the first vessel to be treated. The transcirculating approach (i.e., primary catheterization of a target artery from the contralateral or opposite cerebral circulation) may be an alternative and feasible route in cases where antegrade access and anatomical variants allow it. We describe a representative case of an MVO in a 69-year-old patient with left temporal branch occlusion of the middle cerebral artery (MCA) and P2 segment occlusion of the left posterior cerebral artery (PCA). MCA reperfusion was first performed with a stent retriever via an antegrade approach, and then the PCA approach was performed via the fetal posterior communicating artery using the same technique. Transcirculatory thrombectomy in MVO is the main topic of this chapter.