Challenges in Thrombectomy: Impossible Aortic Arches and Tortuous Vessels

The goal of endovascular treatment is to achieve rapid and safe revascularization of brain tissue at risk for irreversible ischemic injury. Aortic arch anomalies and tortuosity of the vasculature pose a challenge to rapid access to the site of arterial occlusion. In this chapter, we describe different types of aortic arches and discuss technical nuances of access for mechanical thrombectomy. The anatomy of the aortic arch and main blood vessels must be assessed with the help of preprocedure computed tomography angiography. The commonest anomaly of the aortic arch is the bovine type arch in which the left common carotid artery has a common origin with the brachiocephalic (innominate) artery. Another classification of aortic arches is based on the distance of the brachiocephalic artery origin from the top of the aortic arch. Difficult tortuosities can be negotiated by appropriate catheter systems and the use of an intermediate catheter. Direct carotid access should be considered when access through a conventional route cannot be obtained.