A 78-year-old woman presented to the emergency room with acute onset of drowsy mentality, gaze palsy and quadriplegia (NIHSS 9). She had a history of hypertension and diabetes. Brain CT scan revealed no definite early ischemic damage and CTA showed steno-occlusion at the left distal VA and bilateral fetal type PCAs. Brain perfusion CT showed perfusion delay in posterior circulation territory. Under local anesthesia, an 6F Envoy^® catheter (Codman) was placed in the left distal VA of distal V2 segment. The angiography revealed the distal VA occlusion (V4 segment) (Fig.1A). Suction thrombectomy was performed twice using 5F Sofia^® catheter (Microvention), and no clot was extracted (Fig. 1B). Recanalization of left distal VA with underlying severe ICAS at the occlusion site (Fig. 1C). Delayed angiogram showed subtle re-occlusion tendency of left distal VA, 0.5mg of intraarterial tirofiban was injected. Successful recanalization (mTICI 2C) with further recanalized paramedian perforating thalamic-mesencephalic arteries on distal BA after SCA branches was achieved (Fig. 1D). Follow-up brain MRI showed acute infarction at the posterior circulation territory including bilateral thalami. MRA showed patent left distal VA with underlying severe ICAS, and vessel wall MRI showed eccentric wall thickening without contrast enhancement or plaque hemorrhage. The patient recovered well at 1 week (NIHSS 0).