Introduction Alternatives to transfemoral access for acute mechanical thrombectomy have been reported and include direct carotid puncture, brachial artery access, and transradial access. This experience is typically based on a rescue scenario where a transfemoral approach is not feasible or has resulted in failure. Large trials have shown the safety of transradial access for coronary intervention with improved morbidity and mortality rates when compared to transfemoral access for cardiology procedures. When considering an alternative access for difficult interventional stroke therapies a primary consideration for using transradial access should be deliberated. This modality has been adapted for ischemic stroke intervention at several centers including our own. However effective, there are instances in which this modality is ineffective or proves difficult to succeed and should be approached with careful consideration.
Methods All patients seeking endovascular therapy secondary to large vessel occlusions and treated by means of radial artery puncture at our center with documented reperfusion outcome were retrospectively reviewed for analysis. In brief, initial consideration for radial approach requires an assessment of coronary vessel tortuosity through CTA. If qualified, a modified Allen’s test is thus performed to determine vascularity and eligibility for radial access. Following artery puncture, a microwire is advanced in adjunct to a 6–7 F sheath, typically a Neuron MAX 088. In cases involving severe aortic arch, a CLARET technique is used, employing the aortic arch and valve to form a loop allowing for access into the more distal neuroanatomy. Once the thrombus is visualized, thrombectomy is carried out in the usual fashion. We identify cases wherein transradial access was employed, either as initial or secondary intentions, with unsuccessful clot engagement.
Results A total of 32 patients met criteria in a retrospective review of our database. Reperfusion to mTICI 2 b/3 was achieved in 78.1% (25/32) of cases. Of the 7 cases unsuccessfully treated through radial access; difficulties in revascularization as specifically relating to this modality were observed in 4 cases. Radial puncture was not attempted in 2 cases due to extreme vessel tortuosity. In the remaining 2 cases wherein transradial axis was attempted, thrombus engagement was unsuccessful, either due to physiological morphology or to the upstream distal location of the thrombus.
Conclusion An inherent limitation of transradial access is the restriction to a 6–7 F catheter; however other factors must be considered when identifying cases amenable to radial access.
These factors include extreme tortuosity, which not only presents a challenge for radial access, but for all access modalities, and patient height. Patients of above average height or have distal occlusions present a true challenge to the efficacy of radial access as current catheters are limited in length, and thus unable to reach the desired destination. These contraindications are important factors when considering this method of approach, but technological advances in this field may overcome some or all of these limitations.
Disclosures K. Sivakumar: None. S. Feuerwerker: None. A. Tiwari: None. D. Turkel-Parrella: None. K. Arcot: None. J. Farkas: None.
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