Purpose: Endovascular therapy (EVT) through the tortuous access route is increasingly performed in neurovascular procedures. In the posterior circulation through the vertebral artery (VA), ischemic complications, including vessel dissection and cerebral vessel infarction, are sometimes observed, especially during navigation of the guiding catheter, because of small vessel diameter and tortuous origin. We describe an adjunctive technique for passing the guiding catheter safely to the tortuous VA and reducing ischemic complication using respiratory displacement of the aortic arch.

Case Presentations: The guidewire is advanced to the origin of the VA until it is caught in the tortuosity. Then we instruct the patient to take a maximum deep inspiration and hold his or her breath. In this manner, the aortic arch and side branches are dislocated to the caudal direction, which reduces the tortuosity of the VA origin and facilitates passage of the guidewire. Here, we discuss three representative cases which demonstrate that our techniques are effective in navigating the catheter to the tortuous VA.

Conclusion: In the EVT of a patient who has a tortuous VA, respiration control under local anesthesia, maximum deep inspiration, and breath holding induce the respiratory dislocation of the aortic arch. This enables safe navigation of the guiding catheter, reduces the likelihood of interruption in blood flow, and helps avoid dissection and ischemic complications during EVT.