CASE REPORT: An 83-year-old right-handed woman presented to the emergency department with acute right middle cerebral artery syndrome on a background of atrial fibrillation, hypertension, hyperlipidemia, and breast cancer. CT angiogram revealed an acute right carotid T occlusion. Right femoral approach thrombectomy with TICI3 reperfusion was achieved after one pass with an aspiration catheter. Intraoperatively, blood pressure (BP) in the right arm fell to far lower values than left arm BP. Subsequent angiography of the right upper extremity revealed complete occlusion of the distal right brachial artery, prompting aspiration thrombectomy in this vessel with the same access and devices used for thrombectomy of the carotid artery. This resulted in partial recanalization of the brachial artery, with residual thrombus in the distal radial artery, which was further retrieved, achieving near complete recanalization and good collateral flow. Postoperatively, perfusion of the right arm was normal.  At 3-month follow-up, the patient had recovered exceptionally well with an mRS of 1 and no evidence of ischemic injury or impaired perfusion in the right arm.