Purpose Rapid recanalization is vital for mechanical thrombectomy (MT) of large vessel occlusion stroke. Trans-femoral and trans-radial approaches for internal carotid catheterization are routinely used in MT. Due to difficult/impossible and time-consuming attempts to access severe type 2/3 aortic arch anatomy and tortuous cervical vasculature, a trans-carotid access is sometimes required. We describe a care series of trans-carotid stroke thrombectomy to assess its technical and clinical efficacy. Additionally, we quantitatively study the overall angular tortuosity from the aortic arch to the carotid bifurcation required for trans-carotid access, comparing against successful trans-femoral access age-matched controls.

Methods We retrospectively studied 8 patients that underwent MT for anterior circulation acute ischemic stroke between Jan 2015 to June 2019 requiring trans-carotid access. Using age-matched controls (>80 years of age), we compared demographics, presentations, complications, technical and clinical efficacy. All 8 cases of carotid access and 8 age-matched controls were also qualitatively and quantitatively analyzed for aortic arch anatomy type and number of cervical vascular tortuosity segments >90 degrees. Using CTA 3D reconstructions, angular path changes were summated along the segmented vessel from the aortic arch to the carotid bifurcation and analyzed as a sum of angular tortuosity from the horizontal baseline of the aortic arch. Chi-square was used for categorical variables univariate analysis while Mann-Whitney U and student t-tests were used for continuous variables univariate analysis as appropriate based on the distribution normality.

Results Both trans-carotid and control groups matched in age (89.8 and 89.6 years respectively), and both groups were comparable regarding their NIHSS (16 vs 20, p=0.26), side of occlusion (right, 62.5% vs 37.5%, p=0.32), and risk factors of hypertension, DM, hyperlipidemia, smoking, CHF, or AF (p=0.52, 1, 0.13, 1, 0.32, 0.36 respectively). However, the transcarotid group presented with a higher incidence of previous stroke/TIA (62.5% vs 12.5%, p=0.04). The mean number of more than 90-degree tortuous segments was higher and was trending to be significant in transcarotid cohort (1.2 +-0.8 vs 0.3 +- 0.75, p=0.55). The sum of angle tortuosity (371 +- 165 vs 214 +- 86, p=0.14), and the presence of type 3 aortic arch (62.5% vs 25%, p=0.13) were higher in the trans-carotid group, but not statistically significant. There was no difference between groups regarding the 90-days mRS outcome (3.88 vs 3.87, p=0.95). Two patients in transcarotid group suffered an iatrogenic cervical ICA dissection and a small pseudoaneurysm 1 × 5 mm without incident. Two patients also developed neck hematomas that were managed with conservative manual compression.

Conclusion A trans-carotid approach is a relatively safe alternative to transfemoral approach in MT, and may be considered in patients with a type 3 aortic arch, cervical vasculature with >1 tortuous segment (>90 degrees), and/or an angular tortuosity summing >360 degrees from the aortic arch to the carotid bifurcation. These patients were more likely to be older and have a history of previous stroke/TIA.

Disclosures M. Aly: None. R. Abdalla: None. M. Hurley: None. A. Shaibani: None. S. Ansari: None.