Transradial versus transfemoral access for anterior circulation mechanical thrombectomy: comparison of technical and clinical outcomes

Chen, Stephanie H.; Snelling, Brian; Sur, Samir; Shah, Sumedh S.; McCarthy, David; Luther, Evan; Yavagal, Dileep R.; Peterson, Eric C.; Starke, Robert M.

doi:10.1136/neurintsurg-2018-014485

Cited by 119 publications

(84 citation statements)

References 18 publications

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“…The authors have no experience with transradial approaches for stroke, though we are aware of series describing success in both the anterior and posterior circulations. 27,28 Prospective study of patients with anatomy that may prove more difficult to access via a transfemoral route using such alternative methods would benefit the community.…”

Section: Discussionmentioning

confidence: 99%

Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Patients with Acute Ischemic Stroke

Knox¹,

Alexander

McCoy³

et al. 2020

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Arterial access is a technical consideration of mechanical thrombectomy that may affect procedural time, but few studies exist detailing the relationship of anatomy to procedural times and patient outcomes. We sought to investigate the respective impact of aortic arch and carotid artery anatomy on endovascular procedural times in patients with large-vessel occlusion. MATERIALS AND METHODS: We retrospectively reviewed imaging and medical records of 207 patients from 2 academic institutions who underwent mechanical thrombectomy for anterior circulation large-vessel occlusion from January 2015 to July 2018. Preintervention CTAs were assessed to measure features of the aortic arch and ipsilateral great vessel anatomy. These included the cranial-to-caudal distance from the origin of the innominate artery to the top of the aortic arch and the takeoff angle of the respective great vessel from the arch. mRS scores were calculated from rehabilitation and other outpatient documentation. We performed bootstrap, stepwise regressions to model groin puncture to reperfusion time and binary mRS outcomes (good outcome, mRS # 2). RESULTS: From our linear regression for groin puncture to reperfusion time, we found a significant association of the great vessel takeoff angle (P 4 .002) and caudal distance from the origin of the innominate artery to the top of the aortic arch (P 4 .05). Regression analysis for the binary mRS revealed a significant association with groin puncture to reperfusion time (P , .001). CONCLUSIONS: These results demonstrate that patients with larger takeoff angles and extreme aortic arches have an association with longer procedural times as approached from transfemoral access routes. ABBREVIATIONS: CCA 4 common carotid artery; CCIA 4 the cranial-to-caudal distance from the origin of the innominate artery to the top of the aortic arch; GPRT 4 groin puncture to reperfusion time; HTN 4 hypertension; LVO 4 large-vessel occlusion I schemic stroke is the fifth leading cause of death and the leading cause of long-term disability in the United States. 1 Recent studies have established mechanical thrombectomy as the criterion standard of care for large-vessel occlusion over tPA alone. 2-5 These and other studies have demonstrated that reduced time between the onset of symptoms and reperfusion leads to better clinical outcomes. 6,7 That time interval comprises prehospital

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Section: Discussionmentioning

confidence: 99%

Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Patients with Acute Ischemic Stroke

Knox¹,

Alexander

McCoy³

et al. 2020

AJNR Am J Neuroradiol

View full text Add to dashboard Cite

show abstract

“…A recent study by Chen et al has demonstrated equivalence in efficacy and efficiency between trans-radial and trans-femoral approach for mechanical thrombectomy in anterior circulation stroke,20 and there are reports in the literature of success through the trans-radial approach when a trans-femoral approach has failed 16. Trans-radial is preferred over trans-brachial as the puncture site is easily compressible.…”

Section: Discussionmentioning

confidence: 99%

Direct carotid puncture for endovascular thrombectomy in acute ischemic stroke

Roche

Griffin

Looby

et al. 2019

J NeuroIntervent Surg

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BackgroundMechanical thrombectomy is the standard of care for acute ischemic strokes with proximal intracranial occlusion. Arterial access is commonly achieved with femoral artery puncture, although this is not always possible. In this case series, we describe 11 cases of anterior circulation stroke where direct carotid puncture was used to obtain vascular access.Methods and materialsA review of a prospectively maintained thrombectomy database over a 2-year period (August 2016 – August 2018) was undertaken to identify cases where direct carotid access was performed. CT and angiographic imaging were reviewed. Indications for carotid access, techniques used, technical success of procedure, recanalization rates, procedure-related complications, and patient outcomes were assessed.ResultsEleven patients out of 498 overall thrombectomy procedures (2.2% thrombectomies) underwent direct carotid access. Median National Institutes of Health Stroke Scale was 20. Seventy three percent of patients received intravenous thrombolysis. The direct carotid approach was performed following the failed femoral approach due to unfavorable aortic arch anatomy, vessel tortuosity, and severe atherosclerotic disease. Direct carotid puncture was successful in 10 patients, and unsuccessful in one. Successful recanalization (TICI 2b–3) was achieved in eight patients. One patient had spontaneously recanalized on angiography. There was failed recanalization in one patient with tandem ICA and M1 occlusion. Carotid access complications included one patient with both neck hematoma and asymptomatic ICA dissection, and one of delayed central retinal artery occlusion.ConclusionThis case series highlights direct carotid puncture as a successful alternative when the femoral approach is not possible, allowing thrombectomy in patients who would otherwise be unsuitable.

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“…In a retrospective review of 51 patients with challenging vascular anatomy who underwent mechanical thrombectomy for anterior circulation large vessel occlusions, there were no significant differences in technical outcome and efficacy between the transradial and transfemoral groups 8. There were also no complications associated with radial artery access 8. The decision to switch from the femoral to the radial approach has been reported to take nearly 2 hours in an early report, which illustrated that radial was feasible but that alternate access sites need to be contemplated earlier in the procedural course 7.…”

Section: Discussionmentioning

confidence: 95%

“…The transradial approach is a feasible alternative when unfavorable iliofemoral or aortic anatomy is noted 7. In a retrospective review of 51 patients with challenging vascular anatomy who underwent mechanical thrombectomy for anterior circulation large vessel occlusions, there were no significant differences in technical outcome and efficacy between the transradial and transfemoral groups 8. There were also no complications associated with radial artery access 8.…”

Section: Discussionmentioning

confidence: 99%

Balloon anchoring technique forthrombectomyin hostile craniocervical arterial anatomy

Sharashidze

Nogueira

Grossberg

et al. 2020

J NeuroIntervent Surg

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BackgroundCraniocervical catheter access in large vessel occlusion acute ischemic strokes can be challenging in cases of unfavorable aortic arch/cervical vascular anatomy, leading to lower recanalization rates, increased procedural time and worse clinical outcomes. We aim to demonstrate the feasibility of the balloon-anchoring technique (BAT) that can be attempted before switching to alternative access sites.MethodsRetrospective review of prospectively collected information on 11 patients in which two variants of the BAT (proximal anchoring: balloon guide catheter (BGC) is inflated to provide support for distal access; distal anchoring: compliant balloon is inflated in an intracranial artery to allow advancement of the support system) were utilized to facilitate craniocervical access due to failure of conventional maneuvers.ResultsTen patients had anterior and one patient had posterior circulation large vessel occlusions. Mean age was 81 years and 81% were females. Type 3 arches were found in 82% and a 9 French balloon guide catheter was used in 82%. Proximal anchoring with BGC was used in four cases while distal anchoring was used in seven patients to allow access to the target vessel, avoiding the need to puncture alternative access sites. Successful reperfusion (modified treatment in cerebral ischemia 2b-3) was achieved in all cases and no complications were observed.ConclusionBAT is safe and feasible. It can be considered as a rescue maneuver in order to avoid switching to a different access during thrombectomy in individuals with unfavorable aortic arch/craniocervical anatomy.

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Transradial versus transfemoral access for anterior circulation mechanical thrombectomy: comparison of technical and clinical outcomes

Cited by 119 publications

References 18 publications

Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Patients with Acute Ischemic Stroke

Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Patients with Acute Ischemic Stroke

Direct carotid puncture for endovascular thrombectomy in acute ischemic stroke

Balloon anchoring technique forthrombectomyin hostile craniocervical arterial anatomy

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