BackgroundFemoral access is the primary route for neurointerventional procedures in children. However, endovascular treatment may not always be possible through a femoral approach, necessitating conversion to alternative access routes.ObjectiveTo review the feasibility and safety of direct carotid puncture (DCP) in infants undergoing neuroendovascular interventions.MethodsWe conducted a retrospective review of all infants who underwent DCP as the access route to treat neuroendovascular pathologies between January 2011 and January 2021. Patients’ demographics, clinical presentation, imaging findings, and technical details were reviewed.ResultsBetween January 2011 and January 2021, five infants aged between 28 and 150 days underwent DCP out of 1129 neuroendovascular interventions performed in our institution (0.4%). All five infants (100%) were diagnosed with intracranial fistulas and were found to have severe tortuosity of the cervical arteries. DCP was performed as the initial access route in 2/5 patients and as crossover after a failed femoral attempt in 3/5 patients. DCP was performed under ultrasound guidance in all patients. Closure was performed by manual compression, without complications. Ultrasound showed patent cervical vessels in all patients at 3 months’ follow-up.ConclusionDirect carotid access is a feasible and safe alternative route to treat neuroendovascular pathologies in infants and can be considered in cases of inaccessible or failed transfemoral access or in cases with severe arterial tortuosity in infants with intracranial fistulas.