Article Text

Download PDFPDF
Original research
Carotid artery direct access for mechanical thrombectomy: the Carotid Artery Puncture Evaluation (CARE) study
  1. Victor Dumas1,
  2. Johannes Kaesmacher2,
  3. Julien Ognard3,
  4. Géraud Forestier4,
  5. Cyril Dargazanli5,
  6. Kevin Janot6,
  7. Daniel Behme7,
  8. Eimad Shotar8,
  9. Emmanuel Chabert9,
  10. Stéphane Velasco10,
  11. Nicolas Bricout11,
  12. Wagih Ben Hassen12,
  13. Louis Veunac13,
  14. Maxime Geismar14,
  15. Francois Eugene15,
  16. Lili Detraz16,
  17. Jean Darcourt17,
  18. Vincent L'Allinec18,
  19. Omer F Eker19,
  20. Arturo Consoli20,
  21. Volker Maus21,
  22. Florent Gariel22,
  23. Gaultier Marnat22,
  24. Panagiotis Papanagiotou23,
  25. Chrisanthi Papagiannaki24,
  26. Simon Escalard25,
  27. Lukas Meyer26,
  28. Donald Lobsien27,
  29. Nuran Abdullayev28,
  30. Vanessa Chalumeau29,
  31. Jean Philippe Neau30,
  32. Rémy Guillevin1,
  33. Gregoire Boulouis6,
  34. Aymeric Rouchaud4,
  35. Hanna Styczen31,
  36. Cédric Fauché10
  37. on behalf of the JENI, SFNR and the YOUNICORN Research collaborations
    1. 1 Radiology Department, Poitiers University Medical Center, LabCom I3M, DACTIM-MIS team, LMA CNRS 7348, Poitiers, Vienne, France
    2. 2 University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
    3. 3 Interventional Neuroradiology, CHRU de Brest, Brest, Bretagne, France
    4. 4 Neuroradiology Department, XLIM CNRS, UMR7252, Centre Hospitalier Universitaire de Limoges, Limoges, Limousin, France
    5. 5 Department of Neuroradiology, INSERM U1191, University Hospital Center Montpellier, Montpellier, Occitanie, France
    6. 6 Neuroradiology Department, University Hospital of Tours, Tours, Indre et Loire, France
    7. 7 Institute for Diagnostic and Interventional Neuroradiology, University of Gottingen, Goettingen, Germany
    8. 8 Neuroradiology Department, Pitié-Salpêtrière Hospital, Paris, France
    9. 9 Neuroradiology Department, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
    10. 10 Radiology Department, Poitiers University Medical Center, Poitiers, Vienne, France
    11. 11 Department of Interventional Neuroradiology, Centre Hospitalier Regional Universitaire de Lille, Lille, France
    12. 12 Interventional Neuroradiology, CH Sainte-Anne, INSERM UMR 1266, Paris, Île-de-France, France
    13. 13 Department of Radiology, Bayonne Hospital, Bayonne, France
    14. 14 Neuroradiology Department, Centre Hospitalier Universitaire de Caen, Caen, France
    15. 15 Neuroradiology Department, CHU Rennes, Rennes, France
    16. 16 Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nantes, Nantes, France
    17. 17 Neuroradiology Department, CHU Toulouse, Toulouse, Midi-Pyrénées, France
    18. 18 Radiology Department, CHU Angers, Angers, France
    19. 19 Neuroradiology Department, Neurologic Hospital, Bron, France
    20. 20 Interventional Neuroradiology, Hospital Foch, Suresnes, France
    21. 21 Institute of Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Bochum, Ruhr-University, Bochum, Germany
    22. 22 Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, Aquitaine, France
    23. 23 Department of Diagnostic and Interventional Neuroradiology, Hospitals Bremen-Mitte, Bremen-Ost, Germany
    24. 24 Radiology Department, CHU Rouen, Rouen, Normandie, France
    25. 25 Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, Ile de France, France
    26. 26 Diagnostic and Interventional Neuroradiology, Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
    27. 27 Institute of Diagnostic and Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
    28. 28 Diagnostic and Interventional Radiology Department, University Hospital Cologne, Köln, Germany
    29. 29 Interventional Neuroradiology, CHU Bicêtre, Le Kremlin-Bicêtre, Paris, France
    30. 30 Neurology Department, CHU de Poitiers, Poitiers, Vienne, France
    31. 31 Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
    1. Correspondence to Dr Victor Dumas, Radiology, CHU Poitiers Pôle imagerie diagnostique fonctionnelle et thérapeutique, 86000 Poitiers, France; dumasvictor{at}


    Background In acute ischemic stroke due to anterior large vessel occlusion (AIS-LVO), accessing the target occluded vessel for mechanical thrombectomy (MT) is sometimes impossible through the femoral approach. We aimed to evaluate the safety and efficacy of direct carotid artery puncture (DCP) for MT in patients with failed alternative vascular access.

    Methods We retrospectively analyzed data from 45 stroke centers in France, Switzerland and Germany through two research networks from January 2015 to July 2019. We collected physician-centered data on DCP practices and baseline characteristics, procedural variables and clinical outcome after DCP. Uni- and multivariable models were conducted to assess risk factors for complications.

    Results From January 2015 to July 2019, 28 149 MT were performed, of which 108 (0.39%) resulted in DCP due to unsuccessful vascular access. After DCP, 77 patients (71.3%) had successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) score ≥2b) and 28 (25.9%) were independent (modified Rankin Scale (mRS) score 0–2) at 3 months. 20 complications (18.5%) attributed to DCP occurred, all of them during or within 1 hour of the procedure. Complications led to extension of the intubation time in the intensive care unit in 7 patients (6.4%) and resulted in death in 3 (2.8%). The absence of use of a hemostatic closure device was associated with a higher complication risk (OR 3.04, 95% CI 1.03 to 8.97; p=0043).

    Conclusion In this large multicentric study, DCP was scantly performed for vascular access to perform MT (0.39%) in patients with AIS-LVO and had a high rate of complications (18.5%). Our results provide arguments for not closing the cervical access by manual compression after MT.

    • thrombectomy
    • stroke
    • artery
    • complication

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

    Statistics from

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

    View Full Text


    • Twitter @dumasvictor2, @vincelal, @gboulouis

    • GB and AR contributed equally.

    • HS and CF contributed equally.

    • Collaborators JENI, SFNR and the YOUNICORN Research collaborations: Cyril Chivot, Riyad Hanafi (CHU Amiens-Picardie 80054 Amiens Cedex 1, France); Vincent L’Allinec, Jean Baptiste Girot, Anne Pasco Papon, Emeline Berthier (Radiology Department, Angers University Hospital, Angers, France); David Higué, Hélène Cailliez, Laurent Lagoarde (Radiology Department, Hospital of Bayonne, 64100, Bayonne); Gralla Jan, Mordasini Pasquale, Piechowiak Eike I., Dobrocky Tomas, (University Institute of Diagnostic and Interventional Neuroradiology University Hospital Bern, Bern, Switzerland); Fischer Urs, Arnold Marcel, (Department of Neurology, University Hospital Bern, Bern, Switzerland); Guillaume Charbonnier, Aleandra Biondi, Fortunato Di Caterino, Panagiotis Primikiris, Giovanni Vitale (Department of Neuroradiology and Endovascular Therapy, CHU Besançon, France); Louise Bonnet (Neurology Department, CHU Besançon, Besançon, France); Sebastian Fischer (Department of Radiology, Neuroradiology and Nuclear Medicine, Ruhr-University Bochum, University Medical Center Langendreer, Bochum, Germany); Jerome Berge, Xavier Barreau, Patrice Menegon, Thomas Tourdias, Vincent Dousset (Department of neuroradiology, Hopital Pellegrin – University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076 Bordeaux, France) Igor Sibon (Department of neurology, Hopital Pellegrin – University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076 Bordeaux, France); Jean Christophe Gentric (Functional unit of interventional neuroradiology, medical imaging department, Brest University Hospital, La Cavale Blanche, Boulevard Tanguy-Prigent, 29609 Brest, France); Charlotte Barbier, Marion Boulanger, Julien Cogez, Sophie Guettier, Romain Schneckenburger, Emmanuel Touze (University Hospital of Caen, Caen, France), Louis Boyer, Béatrice Claise, Ricardo Moreno, Abderrahim Zerroug, Sonia Mirafzal, (Department of Neuroradiology, CHU Clermont-Ferrand, France); Frederico Bolognini, Pablo Ariel Lebedinsky, Mariette Delaitre, Mariano Musacchio (Department of Radiology, Colmar, France); Christoph Kabbasch (Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany); Adrien Vilain, Titien Tuilier, Erwah Kalsoum, Aurelien Pacini, Chawkat Ramadane (Department of Neuroradiology, APHP, Henry Mondor Hospital, 94000 Créteil, France); Pierre Olivier Comby, Pierre Thouant, Frédéric Ricolfi (Department of Neuroradiology, CHU Dijon, France); Joachim Klisch, Christin Clajus (Department of diagnostic and Interventionnal Radiology and Neuroradiology, Helios Klinikum Erfurt, Germany); Alexander Radbruch (Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany); Amélie-Carolina Hesse, Jan Liman, Ilko Maier (Institute for Diagnostic and Interventional Neuroradiology, University Hospital Goettingen, Goettingen, Germany); Jens Fiehler (Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany); Vanessa Chalumeau, Jildaz Caroff, Laurent Spelle, Christian Denier, Olivier Chassin, Laura Venditti (Department of Interventional Neuroradiology, CHU Bicêtre, Le Kremlin Bicêtre, France); Nicolas Bricout, Thomas Personnic, Laurent Estrade, Apolline Kazemi, Fouzi Bala, François Caparros, Barbara Casolla, Lucie Della Schiava, Nelly Dequatre, Hilde Henon, Marco Pasi, Charlotte Cordonnier (Department of Diagnostic and Interventional Neuroradiology & Stroke Unit, Hopital Roger Salengro, CHR Lille, Lille Cedex, France); Clément Bogey, Suzanna Saleme, Charbel Mounayer (Service de Neuroradiologie interventionnelle CHRU Dupuytren 2 avenue Martin Luther King 87042 Limoges Cedex); François Cotton, Karine Blanc-Lasserre, Serkan Cakmak, Tae-Hee Cho, Laurent Derex, Anne Claire Lukaszewicz, Laura Mechtouff, Norbert Nighoghossian, Frédéric Philippeau, Roberto Riva, Francis Turjman, Anne-Evelyne Vallet (Department of Interventional Neuroradiology, Hospices Civils de Lyon, France); Xavier Carle, Philippe Dory-Lautrec, Anthony Reyre, Jean-François Hak, Hervé Brunel (Department of Neuroradiology, CHU Marseille, France; H. BRUNEL, Department of Neuroradiology, CHU Marseille, France); Medhi Mahmoudi, Amel Benali, François-Louis Collemiche, Frederico Cagnazzo, Imad Derraz, Caroline Arquizan, Lucas Corti, Vincent Costalat, Nicolas Gaillard, Grégory Gascou, Pierre Henri Lefèvre, Isabelle Mourand, Carlos Riquelme (Neuroradiology Department, Gui de Chauliac Hospital, Montpellier, France); François Zhu, Anne Laure Derelle, Benjamin Gory, Liang Liao, Romain Tonnelet, René Anxionnat, Mathieu Bonnerot, Serge Bracard, Marc Braun, Lisa Humbertjean, Jean-Christophe Lacour, Gioia Mione, Sophie Planel, Sebastien Richard, Nolwenn Riou-Comte, Emmanuelle Schmitt (Service de Neuroradiologie Diagnostique et Thérapeutique CHRU Nancy, France); Romain Bourcier (Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, INSERM, CNRS, UNIV Nantes, l’Institut du Thorax, Nantes, France); Hubert Desal, Pierre-Louis Alexandre, Benjamin Daumas-Duport, Cédrix Lenoble, Monica Roy (Interventional Neuroradiology Department, CHU Nantes, France); Jacques Sedat (Interventional Neuroradiology Department, CHU Nice, France); Alexandre Faury (Service d'imagerie médicale, Centre Hospitalier de la Polynésie Française, Papeete, France), François Delvoye, Solène Hebert, Raphaël Blanc, Gabriele Ciccio, Jean-Philippe Desilles, Benjamin Maier, Mikael Mazighi, Pichel Piotin, Hocine Redjem, Stanislas Smajda, Malek Ben Maacha (Department of Interventional Neuroradiology, Fondation Rothschild, 25 rue Manin, 75019, Paris, France); Alexis Guedon, Marc-Antoine Labeyrie, Armand Aymard, Jean Betty, Vittorio Civelli, Michael Eliezer, Matteo Fantoni, Emmanuel Houdart, Jean-Pierre Saint Maurice (Department of Neuroradiology, Lariboisière Hospital, Paris, France); Frédéric Clarençon Nader-Antoine Sourour, Vincent Degos, Ahmed Elhfnawy, Mahmoud Elhonary, Stéphanie Lenck, Kevin Premat (AP-HP, Service de Neuroradiologie Interventionnelle, Hôpital de la Pitié-Salpêtrière, Paris, France); Flore Barronet-Chauvet (Neurologie Vasculaire, Hôpital Pitié-Salpêtrière, Paris, France) ; William Boisseau (Service de Neurologie, Hôpital Saint-Antoine, Paris, France); Olivier Naggara, Denis Trystram, Christine Rodriguez-Regent, Basile Kerleroux(Université Paris-Descartes,INSERM UMR 1266, Department of Neuroradiology, CH-Sainte-Anne, Paris, France) ; Pierre Seners, Guillaume Turc (Université Paris-Descartes, INSERM UMR 1266, Department of Neurology, CH-Sainte-Anne, Paris, France); Samy Boucebci, Ayoub Guerrab, Pier-Olivier Duboë, Jean Pierre Tasu, Guillaume Herpe, Nicolas Raynaud, Brice Bergougnoux, Pierre Daubé (Department of Radiology, CHU Poitiers, France); Matthias Lamy, Chloé Fabien, Marie Camuzeaux (Department of Neurology, CHU Poitiers, France); Julia Prigent (Department of Neurology, CH La Rochelle, France); Johann Sebastian Richter, Alexis Gonnet, Regis Hubrecht (Service d'Imagerie Médicale, Centre Hospitalier de Pau, France) ; Pierre-François Manceau, Sébastien Soize, Solène Moulin (Interventional Neuroradiology Department, CHU de Reims, Université Reims-Champagne Ardenne, France); Christophe Paya, Jean-Christophe Ferre, Jean Yves gauvrit, Sophie Lagnier-Lemercier, Maria Lassale, Helene Raoult, Thomas Ronziere, Clément Tracol, Stéphane Vannier (Interventional Neuroradiology Department, Neurology Department ; CHU Rennes, France); Julien Le Moal (service de Radiologie, unité de Neuroradiologie Interventionnelle, CHU Charles Nicolle, Rouen, France); Marc Bintner, Jean Brice Veyrieres, Pascale Gauthier (Service de Neuroradiologie, CHU groupe hospitalier Sud-Réunion, Saint-Pierre, France); Raoul Pop, Remy Beaujeux, Anca Hasiu, Monica Manisor, Dan Mihoc, Stéphane Kremer (Department of Interventional Neuroradiology, University Hospital of Strasbourg, Strasbourg, France); Bertrand Lapergue, Oghuzan Coskun, Frederico Di Maria, Georges Rodesch, Adrien Wang, David Weisenburger-Lile, Sergio Zimatore, Nadia Ajili, Géraldine Buard, Serge Evrard, Lucas Gorza, Julie Gratieux, Morgan Leguen, Sylvie Marinier, Fernando Pico, Roxanna Poll, Haja Rakotoharinandrasana, Philippe Tassan, Maya Tchikviladze (Stroke Unit, Hôpital Foch, 40 rue Worth 92150 Suresnes, France); Charles Arteaga (Service de Radiologie, Hôpital d'Instruction des armées Sainte Anne, Toulon, France); Elie Lteif, Christophe Cognard, Anne Christine Januel, Frabrice Bonneville, Philippe Tall (service de neuroradiologie diagnostique et interventionnelle du CHU de Toulouse, Hôpital Pierre Paul Riquet, chu toulouse, France); Pierre Guedin, Hocine Redjem (Service de Radiologie, Clinique Des Cèdres, Château D’Alliez, 31700 Cornebarrieu); Denis Herbreteau, Richard Bibi, Fakhreddine Boustia, Igor Malonado (Neuroradiologie Diagnostique et Interventionnelle, Hôpital Bretonneau, CHRU Tours, France); Anthony Le Bras (Service d’Imagerie Médicale, Centre Hospitalier Bretagne Atlantique, 56017, Vannes, France).

    • Contributors VD is the guarantor of this study. All authors have made substantial contributions to the conception or design of the work or the acquisition, analysis or interpretation of data. They were involved in drafting the work or revising it critically for important intellectual content. All authors gave final approval of the version published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.