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To describe the multi-wire technique that facilitates cannulation of the carotid artery during angioplasty and stenting in patients with difficult neck anatomy.When cannulation of the common carotid artery (CCA) was not effective with a 5-F diagnostic mammary artery catheter and standard single-wire technique, a 0.035-inch hydrophilic guidewire was advanced into the external carotid artery (ECA) with the aid of the road map technique and 6-mL injections of contrast. The catheter was exchanged for an 8-F MPA guiding catheter. If the first attempt to advance the guide catheter failed, an additional 2 or 3 hydrophilic guidewires were placed within the ECA to advance the guiding catheter to the CCA, paving the way for carotid angioplasty. Of 140 patients referred to our center with hostile neck anatomies, this technique had been employed in 30 (21%) patients (26 men; mean age 78±6 years): 15 (50%) had type III aortic arch, 7 (23%) had severe tortuosity of the CCA, and 8 (27%) had angulated takeoffs of the carotid or internal arteries. The 2-wire technique was used in 17 patients, 3 wires in 9 patients, and 4 wires in 4 patients. Successful cannulation and correct stent deployment were achieved in all patients. Fluoroscopy time was longer in hostile neck patients compared with others (7.2±3.1 versus 3.8±2.3 minutes, p<0.01).The multi-wire techniques appear to be a safe and effective method to aid cannulation and angioplasty of carotid arteries in patients with hostile neck anatomy.