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Case series
Radial first or patient first: a case series and meta-analysis of transradial versus transfemoral access for acute ischemic stroke intervention
  1. Adnan H Siddiqui1,2,3,4,5,
  2. Muhammad Waqas1,3,
  3. Jenna Neumaier6,
  4. Jeff F Zhang6,
  5. Rimal H Dossani1,3,
  6. Justin M Cappuzzo1,3,
  7. Russell J Van Coevering III7,
  8. Hamid H Rai1,3,
  9. Andre Monteiro1,3,
  10. Ashish Sonig1,3,
  11. Jason M Davies1,3,4,5,8,
  12. Kenneth V Snyder1,3,4,5,
  13. Elad I Levy1,2,3,4,5
  1. 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
  2. 2Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
  3. 3Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
  4. 4Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
  5. 5Jacobs Institute, Buffalo, New York, USA
  6. 6Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
  7. 7Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
  8. 8Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
  1. Correspondence to Dr Elad I Levy, University at Buffalo Neurosurgery, 100 High Street, Suite B4, Buffalo, New York 14203, USA; ELevy{at}


Background Few studies have compared technical success and effectiveness of transradial access (TRA) versus transfemoral access (TFA) for mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We compared the two approaches for technical success, effectiveness, and outcomes.

Methods We retrospectively compared TRA with TFA for AIS MT at our institute. We additionally performed a systematic review and meta-analysis of studies describing the use of TRA alone or in comparison with TFA for MT. Primary outcomes included rate of successful reperfusion (thrombolysis in cerebral infarction (TICI) >2b), number of passes, access-site complications, and 3- month mortality and favorable functional outcomes (modified Rankin Scale (mRS) score 0–2).

Results A total of 222 consecutive patients (TRA=93, TFA=129) were included in our case series. The rate of successful reperfusion was significantly higher for the TFA cohort (91.4% vs 79.6%, P=0.01) with lower mean number of passes (1.8±1.2 vs 2.4±1.6, P=0.014). Three-month mortality in the TFA group was lower (22.1% vs 40.9% for the TRA cohort (P=0.004), with a higher rate of favorable functional outcomes (51.3% vs 34.1%, P=0.015). A meta-analysis of 10 studies showed significant heterogeneity in rates of successful reperfusion (57.1% to 95.6%, heterogeneity=67.55%, P=0.001). None of the previous comparative studies reported 3-month mortality and functional outcomes.

Conclusions This case series demonstrate a higher successful reperfusion rate, fewer passes, lower 3-month mortality, and improved 3-month functional outcomes with TFA. The systematic review highlights the inadequacy of existing evidence. Prospective comparative studies are needed before a ‘radial-first’ approach can be adopted for stroke intervention.

  • intervention
  • stroke
  • technology
  • thrombectomy
  • technique

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  • Contributors Conception and design: AHS, MW, EIL. Acquisition of the data: all authors. Analysis and interpretation of the data: all authors. Drafting the manuscript: MW. Critically revising the manuscript: all authors. Reviewing submitted version of manuscript: all authors.

  • 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 AHS: Financial interest/investor/stock options/ownership: Adona Medical, Inc., Amnis Therapeutics (purchased by Boston Scientific October 2017), Blink TBI Inc., Buffalo Technology Partners Inc., Cerebrotech Medical Systems, Inc., Cognition Medical, Endostream Medical Ltd., Imperative Care, International Medical Distribution Partners, Neurovascular Diagnostics Inc., Q’Apel Medical Inc., Rebound Therapeutics Corp. (purchased 2019 by Integra Lifesciences, Corp.), Rist Neurovascular Inc., Sense Diagnostics, Inc., Serenity Medical Inc., Silk Road Medical, Spinnaker Medical, Inc., StimMed, Synchron, Three Rivers Medical Inc., Vastrax, LLC, VICIS, Inc., Viseon Inc.; Consultant/advisory board: Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd., Imperative Care, Inc., Integra LifeSciences Corp., Medtronic, MicroVention, Minnetronix Neuro, Inc., Northwest University–DSMB Chair for HEAT Trial, Penumbra, Q’Apel Medical Inc., Rapid Medical, Rebound Therapeutics Corp. (purchased by Integra LifeSciences Corp.), Serenity Medical Inc., Silk Road Medical, StimMed, Stryker, Three Rivers Medical, Inc., VasSol, W.L. Gore & Associates; Principal investigator/steering committee for the following trials: Cerenovus NAPA and ARISE II; Medtronic SWIFT PRIME and SWIFT DIRECT; MicroVention FRED & CONFIDENCE; MUSC POSITIVE; and Penumbra 3D Separator, COMPASS, INVEST, TIGER. JMD: Research grant: National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University at Buffalo; Consulting: Medtronic; Honoraria: Neurotrauma Science, LLC; Shareholder/ownership interests: Cerebrotech, RIST Neurovascular. KVS: Consulting and teaching: Canon Medical Systems Corporation, Penumbra Inc., Medtronic, and Jacobs Institute; Co-Founder: Neurovascular Diagnostics, Inc. EIL: Shareholder/ownership interests: NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, Three Rivers Medical; National principal investigator/steering committees: Medtronic (merged with Covidien Neurovascular) SWIFT Prime and SWIFT Direct Trials; Honoraria: Medtronic (training and lectures); Consultant: Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, StimMed; Advisory board: Stryker (AIS Clinical Advisory Board), NeXtGen Biologics, MEDX, Cognition Medical, Endostream Medical; Site principal investigator: CONFIDENCE study (MicroVention), STRATIS Study—Sub I (Medtronic). MW, JZ, JN, RHD, HHR, AM, JMC, RJVC III, AS: no competing interests disclosed.

  • Patient consent for publication Not required.

  • Ethics approval Written consent was obtained from all patients or their healthcare proxy before procedures were performed. This study was approved by the University at Buffalo institutional review board, STUDY 030-403427.

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

  • Data availability statement Data that support the findings of this study are available from the corresponding author on reasonable request.

  • 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.

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