Dual Radial and Femoral Arterial Access for Mechanical Thrombectomy in Acute Middle Cerebral Artery Occlusion: A Case Report.

BACKGROUND Endovascular treatment (EVT) is essential in managing acute ischemic stroke (AIS), particularly large-vessel occlusions. However, anatomical variations, such as a challenging type III aortic arch, can significantly complicate standard transfemoral arterial access for mechanical thrombectomy. This poses a risk of delaying treatment and impacting patient outcomes. This case report describes a novel hybrid approach to overcome such anatomical challenges. CASE REPORT A 72-year-old woman presented with AIS due to a right middle cerebral artery (MCA) occlusion, exhibiting a NIHSS score of 22. Intravenous alteplase was administered but was ineffective. Angiography confirmed a type III aortic arch variant with approximately a 30-degree angle at the brachiocephalic trunk origin, complicating attempts at selective cannulation of the right common carotid artery via standard femoral access. Following initial unsuccessful femoral attempts, a dual-access strategy was employed. A 5-Fr single-bend snare was delivered via the right radial artery, successfully capturing the 8-Fr femoral sheath. This guided the sheath into the right common carotid artery, facilitating subsequent superselection. Mechanical thrombectomy successfully revascularized the occluded MCA. Despite the complex anatomy and procedural maneuvers, no significant immediate complications were noted on post-procedure imaging. CONCLUSIONS This case highlights the feasibility and benefit of a dual radial and femoral arterial access technique in managing acute MCA occlusion in the setting of a challenging type III aortic arch variant. This hybrid approach, employing a "snare-grasp-fix-guide" strategy, successfully navigated complex anatomy that impeded standard femoral access alone. It underscores the importance of adaptable, individualized access strategies and the potential of combined approaches to optimize device delivery and improve outcomes in challenging neurointerventional procedures.