Tandem occlusions, defined as concurrent extracranial internal carotid artery and intracranial large vessel occlusions. While endovascular thrombectomy (EVT) is effective, the optimal treatment sequence for cervical and intracranial lesions remains unclear. Traditional sequential approaches, whether addressing the cervical or intracranial lesion first, are associated with prolonged procedural times.  Recently, simultaneous EVT techniques have been developed to expedite reperfusion and improve outcomes.

A total of 156 patients from 8 studies underwent simultaneous endovascular revascularization for acute tandem lesions. The median age was 67 years (IQR 50–82), with 74.2% male, a median baseline NIHSS of 15 (IQR 10–20), and 60.3% receiving intravenous thrombolysis. Various simultaneous techniques were used, including the T-Top, ReWiSed CARe, SEIMLESS, CoMBAt, and single-cross methods, all involving stent retrievers, monorail balloon angioplasty, and, in some cases, aspiration catheters. Procedurally, the overall successful recanalization rate (mTICI ≥2b) was 94.2%, with a median puncture-to-recanalization time of 50 minutes (IQR 25–65). First-pass reperfusion ranged from 60–100% depending on the study. Functional outcomes were favorable, with 55.7% achieving mRS 0–2 at discharge and 69.2% at 90 days. Safety events were infrequent: dissection occurred in 0.64%, symptomatic intracranial hemorrhage in 4.5%, periprocedural mortality in 3.2%, and 90-day mortality in 9%. 

Simultaneous EVT for tandem occlusions is efficient, and safe, achieving high reperfusion and favorable outcomes with reduced procedure time. Larger multicenter prospective studies are warranted to validate these findings.