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Ischemic stroke
Original research
Comparison between transradial and transfemoral mechanical thrombectomy for ICA and M1 occlusions: insights from the Stroke Thrombectomy and Aneurysm Registry (STAR)
  1. Michael A Silva1,
  2. Sameh Samir Elawady2,
  3. Ilko Maier3,
  4. Sami Al Kasab4,
  5. Pascal Jabbour5,
  6. Joon-Tae Kim6,
  7. Stacey Q Wolfe7,
  8. Ansaar Rai8,
  9. Marios-Nikos Psychogios9,
  10. Edgar A Samaniego10,
  11. Nitin Goyal11,
  12. Shinichi Yoshimura12,
  13. Hugo Cuellar13,
  14. Jonathan A Grossberg14,
  15. Ali Alawieh15,
  16. Ali Alaraj16,
  17. Mohamad Ezzeldin17,
  18. Daniele G Romano18,
  19. Omar Tanweer19,
  20. Justin Mascitelli20,
  21. Isabel Fragata21,
  22. Adam J Polifka22,
  23. Fazeel M Siddiqui23,
  24. Joshua W Osbun24,
  25. Roberto Javier Crosa25,
  26. Charles Matouk26,
  27. Michael R Levitt27,
  28. Waleed Brinjikji28,
  29. Mark Moss29,
  30. Travis M Dumont30,
  31. Richard Williamson31,
  32. Pedro Navia32,
  33. Peter Kan33,
  34. Reade Andrew De Leacy34,
  35. Shakeel A Chowdhry35,
  36. Alejandro M Spiotta2,
  37. Min S Park36,
  38. Robert M Starke1
  39. STAR Collaborators
  1. 1Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
  2. 2Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  3. 3Neurology, University Medicine Goettingen, Goettingen, Germany
  4. 4Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
  5. 5Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  6. 6Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
  7. 7Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
  8. 8Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
  9. 9Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
  10. 10Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  11. 11Neurology, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
  12. 12Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
  13. 13Neurosurgery, LSUHSC, Shreveport, Louisiana, USA
  14. 14Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
  15. 15Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  16. 16Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
  17. 17Department of Clinical Sciences, HCA Houston Healthcare Kingwood, University of Houston, Kingswood, Texas, USA
  18. 18Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d’Aragona', Salerno, Italy
  19. 19Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  20. 20Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  21. 21Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
  22. 22Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  23. 23Department of Neuroscience, University of Michigan Health-West, Wyoming, Michigan, USA
  24. 24Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
  25. 25Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
  26. 26Neurosurgery, Yale University, New Haven, Connecticut, USA
  27. 27Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
  28. 28Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
  29. 29Neurosurgery, Washington Regional Medical Center, Fayetteville, Arkansas, USA
  30. 30Department of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
  31. 31Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
  32. 32Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
  33. 33Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  34. 34Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  35. 35Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA
  36. 36Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
  1. Correspondence to Dr Michael A Silva, Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA; mas633{at}miami.edu

Abstract

Background The role for the transradial approach for mechanical thrombectomy is controversial. We sought to compare transradial and transfemoral mechanical thrombectomy in a large multicenter database of acute ischemic stroke.

Methods The prospectively maintained Stroke Thrombectomy and Aneurysm Registry (STAR) was reviewed for patients who underwent mechanical thrombectomy for an internal carotid artery (ICA) or middle cerebral artery M1 occlusion. Multivariate regression analyses were performed to assess outcomes including reperfusion time, symptomatic intracerebral hemorrhage (ICH), distal embolization, and functional outcomes.

Results A total of 2258 cases, 1976 via the transfemoral approach and 282 via the transradial approach, were included. Radial access was associated with shorter reperfusion time (34.1 min vs 43.6 min, P=0.001) with similar rates of Thrombolysis in Cerebral Infarction (TICI) 2B or greater reperfusion (87.9% vs 88.1%, P=0.246). Patients treated via a transradial approach were more likely to achieve at least TICI 2C (59.6% vs 54.7%, P=0.001) and TICI 3 reperfusion (50.0% vs 46.2%, P=0.001), and had shorter lengths of stay (mean 9.2 days vs 10.2, P<0.001). Patients treated transradially had a lower rate of symptomatic ICH (8.0% vs 9.4%, P=0.047) but a higher rate of distal embolization (23.0% vs 7.1%, P<0.001). There were no significant differences in functional outcome at 90 days between the two groups.

Conclusions Radial and femoral thrombectomy resulted in similar clinical outcomes. In multivariate analysis, the radial approach had improved revascularization rates, fewer cases of symptomatic ICH, and faster reperfusion times, but higher rates of distal emboli. Further studies on the optimal approach are necessary based on patient and disease characteristics.

  • Thrombectomy
  • Stroke
  • Technique
  • Angiography

Data availability statement

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

https://doi.org/10.1136/jnis-2023-021358

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    Data availability statement

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

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    Footnotes

    • Twitter @sameh_elawady1, @PascalJabbourMD, @esamaniego, @JAGrossbergMD, @rocrossa, @DrMichaelLevitt, @pnavia, @PeterKa80460001, @rdeleacymd, @Starke_neurosurgery

    • Contributors MAS, RMS, SSE, and AMS participated in the conception and design of the study. MAS and RMS contributed to the writing of the manuscript. MAS and SSE contributed to data collection and data analysis. MAS and RMS drafted the manuscript. MAS, SSE, IM, SAK, PJ, JTK, SQW, AR, M-NP, EAS, NG, SY, HC, JAG, AAlawieh, AAlaraj, ME, DGR, OT, JM, IF, AJP, FMS, JWO, RJC, CM, MRL, WB, MM, TMD, RW, PN, PK, RADL, SAC, AMS, MSP, and RMS critically reviewed and revised the manuscript, assisted with interpretation of results, and approved of the final version of the manuscript. RMS and AMS oversaw the study. RMS is the guarantor of the study.

    • Funding The STAR registry currently receives funding from Penumbra, Stryker and Medtronic.

    • Competing interests IM: Speakers' honoraria from Pfizer and Bristol-Myers Squibb. SAK: Grant from Stryker for RESCUE-ICAS registry. RMS: RMS research is supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, Department of Health Biomedical Research Grant (21K02AWD-007000) and by National Institute of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute, from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. RMS has an unrestricted research grant from Medtronic and Balt and has consulting and teaching agreements with Penumbra, Abbott, Medtronic, Balt, InNeuroCo, Cerenovus, Naglreiter, Tonbridge, Kaneka, Von Medical, and Optimize Vascular. M-NP: Grants from the Swiss National Science Foundation (SNF) for the DISTAL trial (33IC30_198783) and TECNO trial (32003B_204977), grant from Bangerter-Rhyner Stiftung for the DISTAL trial, unrestricted grants for the DISTAL trial from Stryker Neurovascular, Phenox GmbH, Penumbra and Rapid Medical, Sponsor-PI SPINNERS trial (funded by a Siemens Healthineers AG grant); research agreement with Siemens Healthineers AG; local PI for the ASSIST, EXCELLENT, TENSION, COATING, SURF and ESCAPE-NEXT trials; speaker fees: Stryker Neurovascular, Medtronic, Penumbra, Acandis, Phenox, Siemens Healthineers. EAS: Consultant for Medtronic, Microvention, Rapid Medical. SY: Lecture fee from Stryker, Medtronic, Johnson & Johnson, Kaneka Medics. HC: Consultant for Medtronic, Penumbra and Microvention. JAG: Grant support: Georgia Research Alliance, Emory Medical Care Foundation, Neurosurgery Catalyst; Consultant: Cognition, Imperative Care. DGR: Consultant for Penumbra, Balt, Microvention, Phenox. OT: Consulting agreements: Viz.AI, Penumbra, Balt, Stryker, Imperative; Proctor: Microvention, Medtronic; Educational/research grants: Q’apel, Steinberg Foundation. CM: Consultant for Stryker, Medtronic, Microvention, Penumbra, and Silk Road Medical; speaker for Penumbra and Silk Road Medical; contact PI for NIH Grant R21NS128641. MSP: Consultant for Medtronic. MRL: Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Medtronic, Aeaean Advisers and Metis Innovative; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, and Hyperion Surgical; editorial boards of Journal of NeuroInterventional Surgery and Frontiers in Surgery. WB: Holds equity in Nested Knowledge, Superior Medical Editors, Piraeus Medical, Sonoris Medical, and MIVI Neurovascular. He receives royalties from Medtronic and Balloon Guide Catheter Technology. He receives consulting fees from Medtronic, Stryker, Imperative Care, Microvention, MIVI Neurovascular, Cerenovus, Asahi, and Balt. He serves in a leadership or fiduciary role for MIVI Neurovascular, Marblehead Medical LLC, Interventional Neuroradiology (Editor in Chief), Piraeus Medical, and WFITN. RW: Consultant for Medtronic, Stryker, and Synaptive Medical. PN: Consultant for Penumbra, Medtronic, Stryker, Cerenovus and Balt. PK: Grants from the NIH (1U18EB029353-01) and unrestricted educational grants from Medtronic and Siemens; consultant for Imperative Care and Stryker Neurovascular; stock ownership in Vena Medical. RADL: PI for Imperative Trial; research grants from Siemens Healthineers and Kaneka Medical; consultant for Cerenovus, Stryker Neurovascular and Scientia Vascular; minor equity interest Vastrax, Borvo Medical, Synchron, Endostream, Von Vascular. SAC: Consultant and proctor for Medtronic and Microvention. ME: Consultant for viz. Ai, Investing in Galaxy Therapeutics. AMS: Research support from Penumbra, Stryker, Medtronic, RapidAI, Avail; consultant for Penumbra, Stryker, Terumo, and RapidAI; equity Avail.

    • 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.