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E-133 Snuffbox access for carotid artery stenting using the bmx-81 guide catheter: technical and anatomic considerations
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  1. B Yim1,2,
  2. I Finch3,
  3. R Peddamallu4,5,
  4. F Zia2,5
  1. 1Neurosurgery, John Muir Health, Walnut Creek, CA
  2. 2East Bay Brain and Spine, Walnut Creek, CA
  3. 3John Muir Hospital, Walnut Creek, CA
  4. 4Neurosurgery, East Bay Brain and Spine, Walnut Creek, CA
  5. 5John Muir Health, Walnut Creek, CA

Abstract

Background Cervical carotid stenting via transradial access has been described using an0.087’ system, however, its widespread adoption has been limited. The radial artery of manypatients struggle to accommodate an 8 French system due to size or severe spasm. While thefirst generation of radial guide catheters have expanded the portfolio of intracranial treatments,including stent-assisted coiling, flow diversion placement, and AVM/fistula embolization,carotid stent placement has lagged behind. The 7 French BMX-81 guide catheter (Penumbra,Alameda, CA) provides a balance between flexibility and rigidity that has advanced the easeand capability of radial access procedures best appreciated with carotid stenting.

Methods The authors present a retrospective study at a single institution between March2023 to March 2024 involving 26 consecutive patients who underwent carotid intervention viaan anatomic snuffbox or ulnar approach using the 95 cm BMX 81 guide catheter and 7 slendersheath (Terumo, Japan). The primary endpoint was successful completion of treatment withoutfemoral access conversion. Secondary endpoints included changes in National Institutes ofHealth Stroke Scale (NIHSS) and modified Rankin Scale (mRS) between pre- and post-procedure, and access artery patency at 6-month follow-up.

Results Successful treatment via snuffbox/ulnar access in 23/26 patients with 3 requiringconversion to femoral access. One patient required radial access after vasospasm wasencountered during attempted snuffbox access. The mean age of the cohort was 67.8±14.1years old with no patients suffering a decline in NIHSS or mRS between pre and post-procedure examinations. Mean distal palmar branch/ulnar artery size was 2.2 ± 0.4 mm. Themost common level of the carotid bifurcation in this cohort was C3–4. Among the eight left-sided treatments, only one patient had a type III aortic arch. In regards to indications, twentypatients had symptomatic (15) or asymptomatic (5) carotid stenosis, four patients had anexpanding dissection/pseudoaneurysm, and one patient each for a floating thrombus and asymptomatic web.Right sided interventions were found to have subclavian to common carotid angulations thatwere more acute than the left, 36.5° vs. 53.8° and shorter catheter purchase length of thecommon carotid artery (8.1 vs. 10.3 cm). Of the patients requiring conversion to a femoralapproach, two were related to peripheral access (proximal bifurcation of the brachial artery andsevere atheterosclerotic disease of the right brachial bifurcation) and one was attributed to acombination of a low carotid bifurcation at C5–6 resulting in a short left-sided common carotidartery (6.5 cm) and external carotid artery occlusion. Within the study population, the followingdevices were implanted: twelve Acculink (Abbott, Chicago, IL), twelve Xact (Abbott, Chicago,IL), one Surpass Evolve (Stryker, Kalamazoo,MI), and one Resolute Onyx (Medtronic,Minneapolis, MN).

Conclusion The BMX-81 guide catheter provides an option to utilize a 7 Fr system to allowsnuffbox access to a wider population and reduce rates of radial artery occlusion. Acutecarotid origin angles, lower carotid bifurcations with shorter common carotid artery lengthsprovide technical challenges to successful transradial/transulnar stenting.

Disclosures B. Yim: 2; C; Imperative Care, Q’Apel. 3; C; Penumbra. I. Finch: None. R. Peddamallu: None. F. Zia: 5; C; East Bay Brain and Spine.

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