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Background Tandem occlusions involving extracranial internal carotid artery (ICA) disease with concomitant intracranial large vessel occlusion represent a complex stroke subtype, particularly in the setting of intravenous thrombolysis. These lesions are associated with worse outcomes and present unique technical and therapeutic challenges. Optimal management remains controversial, especially regarding the role of carotid artery stenting (CAS). The balance between reperfusion benefit and hemorrhagic risk is further complicated by the need for antiplatelet therapy during CAS.Objective To evaluate endovascular strategies, angiographic outcomes, and safety in patients with tandem occlusions treated with intravenous thrombolysis.Methods We retrospectively analyzed patients with tandem occlusions treated following intravenous thrombolysis at a comprehensive stroke center in West Texas between 2023 and 2025. Baseline characteristics, imaging profiles, and procedural details, including angioplasty and CAS, were collected. Primary endpoints included successful reperfusion (TICI ≥2b), first-pass effect (FPE), and CAS technical success. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and procedural complications.Results A total of 24 patients were included. The mean age was 66 ± 13 years, and 52% were female. The median presenting NIHSS score was 15 (IQR 13-19). Most lesions involved ICA-M1 occlusions (75%). A total of 87.5% of patients received TNK, and 12.5% received tPA.Acute CAS was performed in 58.3% of cases. A retrograde (intracranial-first) approach predominated, with frequent use of balloon guide catheters and combined thrombectomy techniques. Only one patient underwent CAS after discharge from the acute ischemic stroke encounter. Within the acute CAS group, 9 of 14 patients underwent balloon angioplasty in conjunction with CAS. Compared with patients who did not undergo acute CAS, there was no significant difference in length of stay (median 7 [IQR 3-8.75] vs 6 [IQR 3.25-12.76]; p = 0.4174). Overall, the median procedural time was 58.5 minutes (IQR 40.3-66.5). Successful reperfusion (TICI ≥2b) was achieved in 88% of patients, with a first-pass effect in 30%. Symptomatic intracranial hemorrhage occurred in 4.16% of patients, while hemorrhagic transformation occurred in 25%.Conclusion Endovascular treatment of tandem occlusions following intravenous thrombolysis yields high reperfusion rates. Acute CAS was not associated with worse short-term outcomes compared with non-CAS management, supporting its use as a safe and effective strategy in appropriately selected patients. Larger studies are needed to further define the optimal revascularization strategy.Disclosures P. Suppakitjanusant: None. S. Bushnaq: None.