Introduction Interventional stroke therapies are quickly becoming the new standard of care for acute large vessel occlusions. Stentrievers and aspiration catheters, while significantly improving recanalization rates, have increased the need for better catheter tracking and stable positioning within the neurovasculature. Difficulties in accessing the target vessel occlusion results in delays and a potential for poor outcome. The main intra-procedural cause for treatment delay and failure-to-treat includes unfavorable vascular anatomy. Type III or bovine aortic arch, extreme tortuosity, aortic aneurysms or severe peripheral vascular disease presents challenging obstacles in access. These anatomical abnormalities can make safe and timely transfemoral access difficult, even impossible at times. Alternative access modes, including transradial access, have proven effective in cardiovascular intervention and may provide advantages in circumventing tortuous vascular anatomy. This modality has been adapted for access in stroke intervention; herein, we present additional results from our previous experience with transradial access for endovascular stroke therapy.
Methods A retrospective review of our stroke database was conducted between January 2013 to February 2016 to identify all patients treated endovascularly through transradial access both as first or second intention. The primary outcome of this study measured the success of radial access in ischemic stroke therapy. Secondary outcome evaluated procedural time between cohorts where radial access was primary versus secondary, and procedural adverse events.
Results In total, 34 patients were identified, 17 were treated transradially as primary, 16 as secondary, and 1 was a tertiary attempt; the median age was 86 years [IQR 74–90].
In patients where radial access was first intentions, the median time from puncture to clot engagement was 69 minutes [IQR 28.5–78] (mean = 70.7 ± 52.4), with successful revascularization achieved in 86.7% (13/15) of patients. Notably, one patient was approached via primary radial access, however resorted to a transfemoral approach; successful revascularization to mTICI 2 c was achieved.
As may be expected, in patients where radial access second intention, time to clot engagement was 91 minutes [IQR 51.5–125.5] (mean = 115.6 ± 53.8) from initial attempts; however, from secondary transradial attempts, median time was 44 minutes [14.0–77.0] (mean = 52.7 ± 46.3).
The median time difference between initial puncture to radial access rescue therapy was 14 minutes [IQR 2–46.5] (mean 35.7 ± 52.0). Success was achieved in 70.6% (12/17) of cases in this cohort. Overall, successful revascularization was achieved in 78.1% (25/32) of patients; mTICI scores were not available in 2 patients. There were 4 peri-procedural complications; however, none were considered related to radial access.
Conclusion While femoral access remains the standard operating procedure for endovascular intervention of acute ischemic stroke, in patients with tortuous vascular anatomy, or having severe femoral disease, access via transfemoral is discouraged. Results from our study demonstrate that radial access is a safe and promising alternative, both as primary and rescue attempts. In an effort to reduce overall procedural time, radial access should be considered for qualified patients. A larger sample size would better validate the present findings.
Disclosures J. Farkas: None. N. Farkas: None. S. Feuerwerker: None. A. Tiwari: None. D. Turkel-Parrella: None. K. Arcot: None. K. Sivakumar: None.
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