Dual-guidewire technique with cerebral embolic protection for brachiocephalic trunk bifurcation stenosis: a case report

Background Severe stenosis at the terminal bifurcation of the brachiocephalic trunk involving the origins of the right common carotid artery and the right subclavian artery is a rare and highly challenging lesion of the supra-aortic vessels. Endovascular intervention carries a high risk of embolization and difficulty in delivering large-diameter stents. Case summary We report a 60-year-old male patient who presented with intermittent dizziness and asymmetric blood pressure in the upper limbs. Color Doppler ultrasound and head and neck CT angiography revealed severe stenosis at the terminal bifurcation of the brachiocephalic trunk (stenosis rate approximately 90%), with the lesion involving the origins of the right common carotid artery and the right subclavian artery, accompanied by right subclavian artery steal phenomenon. The patient underwent brachiocephalic trunk balloon angioplasty and stenting via a single femoral artery access. An embolic protection device was deployed in the C1 segment of the right internal carotid artery for distal cerebral protection. During delivery of the stent, the filter guidewire provided insufficient support; a second guidewire was added as a buddy wire to establish a dual-guidewire rail technique, facilitating successful stent placement. Debris was observed in the retrieved filter. Postoperatively, the severe stenosis was relieved and the steal phenomenon resolved. At 1.5 years of follow-up, the patient reported no recurrence of dizziness, and the inter-arm blood pressure difference remained within the normal range. Conclusion In this selected case with clear antegrade flow direction, a single-access, single-filter strategy appeared feasible and may offer a simplified alternative for similar anatomical presentations. However, further validation in larger case series is warranted. The application of dual-guidewire rail technique to overcome difficulties in large-diameter stent delivery during brachiocephalic trunk intervention has been rarely reported.