Rapid Recanalization Using TrevoProVue through a 4.2 Fr Catheter without a Guiding Catheter via Transbrachial Approach: A Case Report

Abstract

Mechanical thrombectomy with a stent retriever has been reported to achieve high rates of successful recanalization, and reduce disability and mortality in patients with acute ischemic stroke (AIS) due to proximal vessel occlusion. However, in a few cases, the treatment is difficult due to artery tortuosity or other factors. The authors present a case of a 94-year-old man presenting with acute right middle cerebral artery occlusion. We attempted to treat using a stent retriever via transfemoral approach, but failed to advance the guiding catheter into the right internal carotid artery due to femoral artery tortuosity and a type III arch. By changing approaches from transfemoral to transbrachial and by using TrevoProVue through a 4.2 Fr Simmons-type catheter without a guiding catheter, we were able to achieve rapid recanalization in only 26 minutes from brachial artery puncture to reperfusion. In conclusion, rapid reperfusion in an AIS patient was successfully achieved by combining a stent retriever with a 4.2 Fr catheter (without a guiding catheter) and a transbrachial approach (as opposed to a transfemoral approach). When the transfemoral approach is not feasible, we recommend consideration of this strategy as an alternative.

Unfavorable Vascular Anatomy during Endovascular Treatment of Stroke: Challenges and Bailout Strategies

“…The number of puncture attempts may have some influence on the frequency of complications, especially if the patient has received intravenous tissue plasminogen activator (IV tPA). [39][40][41][42][43] In our practice, this is a very rare option used in cases of posterior circulation stroke with very tortuous aortic arch and Figure 5. Use of multiple guidewires in very tortuous extracranial vessel access.…”

“…Case series using the transbrachial approach for the endovascular treatment of AIS suggest that it is a feasible technique and may be considered as an alternative route, particularly in patients with posterior circulation strokes. 39,41,43 Direct carotid puncture When facing unfavorable vascular anatomy during the endovascular treatment of AIS, direct carotid artery access (DCA) is an alternative strategy that provides rapid access to anterior circulation. [44][45][46] Some authors argue that this technique must be the first option after TFA failure in patients with anterior circulation stroke and anatomical variants associated with technically challenging carotid access.…”

“…Others claim that TRA access should be preferred as a first-line option. 43 In their review, Mokin et al 45 provided a detailed description of techniques. They favored the use of ultrasound to visualize and punctured the carotid artery 3 to 4 cm above the clavicle using a 21-gauge micropuncture needle at a 45° angle.…”

“…Thus, careful patient selection and proper technique are paramount. The number of puncture attempts may have some influence on the frequency of complications, especially if the patient has received intravenous tissue plasminogen activator (IV tPA) [ 39 - 43 ].…”

“…Case series using the transbrachial approach for the endovascular treatment of AIS suggest that it is a feasible technique and may be considered as an alternative route, particularly in patients with posterior circulation strokes [ 39 , 41 , 43 ].…”