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Purpose To report use of distal radial artery (dRA) access for carotid artery stenting (CAS) and to discuss procedural setup and technical considerations for a successful intervention. Methods A retrospective review of our prospective neurointerventional database of CAS was conducted between May 2019 and March 2020. All CAS cases via dRA in the anatomical snuffbox were identified. Patient demographics, clinical information, procedural and radiographic data was collected. Results 22 CAS procedures in 20 patients via dRA were identified. Patients’ mean age was 69.4 years (range 53–87 years). 3 patients were female. Mean radial artery diameter was 2.1 mm (range 1.6–2.8 mm). dRA access was achieved in all cases. Conversion to femoral access was required in 2 cases (9.1%) due to persistent radial artery vasospasm resulting in patient discomfort despite multiple additional doses of intraarterial vasodilators and added intravenous sedation as well as tortuous vessel anatomy and limited support of the catheters in a type 3 aortic arch for left CAS. Conclusion Our preliminary experience with dRA access for CAS suggests this approach to be feasible and safe for patients. Technical considerations are important and preprocedural planning is necessary for a successful intervention. Catheter systems and devices specifically designed for radial access are needed to enable more interventionalists to safely perform neurointerventional procedures via wrist access.

BACKGROUND Intracranial dural arteriovenous fistulae (dAVFs) with cortical venous drainage (CVD) require treatment because of their aggressive clinical presentation and natural history. Although endovascular treatment is effective for the majority of these lesions in the current endovascular era, surgical management has been required if the lesions are not amenable to or fail endovascular treatments. OBJECTIVE To demonstrate the angioarchitecture that may necessitate surgical intervention. METHODS A retrospective review of the patients with intracranial dAVFs with CVD treated at 2 academic institutions between January 1, 2009, and July 31, 2019 was performed. Patients who required surgical intervention were selected in this study, and angiographic findings were analyzed. RESULTS A total of 81 dAVFs in 80 patients were treated during the study period. Endovascular treatments were attempted for 72 (88.9%) dAVFs, resulting in complete obliteration in 55 (76.4%). Surgical interventions were performed in 18 (22.2%) dAVFs, resulting in complete obliteration in all lesions. Overall, complete obliteration was achieved in 74 (93.7%) of 79 dAVFs with follow-up. In the surgically treated dAVFs, curative transarterial embolization was deterred by the angioarchitecture, which included dominant feeding vessels from the ophthalmic artery, meningohypophyseal trunk, posterior meningeal artery, pial artery, or ascending pharyngeal artery. Drainage through tortuous cortical vein, deep venous system, or isolated sinus made transvenous approach challenging. CONCLUSION Despite continued improvement in endovascular technology, surgical approaches to dAVFs are still of great value as initial and salvage treatment of dAVFs with angioarchitecture hampering endovascular treatment.

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Objective: Transarterial Onyx embolization is the mainstay of intracranial non-cavernous dural arteriovenous fistulas (dAVFs) treatment. Although the dural arterial supply varies depending on the location, the impact of arterial access on treatment outcomes has remained unclear. The aim of this study was to characterize factors as sociated with complete obliteration following transarterial Onyx embolization, with a special focus on arterial access routes and dAVF location.Methods: A retrospective analysis of the patients who underwent transarterial Onyx embolization for intracranial dAVFs at two academic institutions was performed. Patients with angiographic follow-up were considered eligible to investigate the impact of the arterial access on achieving complete obliteration.Results: Sixty-eight patients underwent transarterial Onyx embolization of intracranial dAVFs. Complete obliteration was achieved in 65% of all treated patients and in 75% of those with cortical venous reflux. Multivariable analysis identified middle meningeal artery (MMA) access to be a significant independent predictive factor for complete obliteration (OR, 2.32; 95% CI, 1.06-5.06; p=0.034). Subgroup analysis showed that supratentorial and lateral cerebellar convexity dAVFs (OR, 5.72, 95% CI, p=0.002), and Borden type III classification at pre-treatment (OR, 3.13, 95% CI, p=0.041), were independent predictive factors for complete obliteration following embolization through the MMA.Conclusions: MMA access is an independent predictive factor for complete obliteration following transarterial Onyx embolization for intracranial non-cavernous dAVFs. It is particularly effective for supratentorial and lateral cerebellar convexity dAVFs and those that are Borden type III.