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Abstract
The recent development of revascularization devices, including stent retrievers, has enabled increasingly higher revascularization rates for arterial occlusions in acute ischemic stroke. Patient-specific factors such as anatomy, however, may occasionally limit endovascular deployment of these new devices via the conventional transfemoral approach. We report three cases of acute ischemic stroke where a transbrachial endovascular approach to revascularization was used, resulting in successful recanalization. These examples suggest that a transbrachial approach may be considered as an alternative in the endovascular treatment of acute ischemic stroke.
- Stent
- Stroke
- Technique
- Catheter
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Introduction
Recent technical advancements in mechanical thrombectomy with stent retrievers for acute ischemic stroke have enabled increasingly higher revascularization rates.1–3 Although transfemoral access is generally used, it is technically difficult and time-consuming in certain anatomic configurations, such as type III aorta, bovine type arch, extreme arterial tortuosity, aortic aneurysm, or arterial elongation. Difficult catheter access is associated with a worse prognosis in acute ischemic stroke.4
For coil embolization of aneurysms or carotid artery stenting in which the standard percutaneous transfemoral access cannot be established because of unfavorable anatomy, alternative approaches such as transbrachial access have been widely used.5–7 However, transbrachial access for acute ischemic stroke, with or without the use of a stent retriever, has not been well documented. This alternative access offers the potential benefits of assuring access to the lesion, and reaching the lesion more quickly than if struggling with a challenging aortic arch anatomy. We present three cases of transbrachial endovascular recanalization for acute ischemic stroke, including use of new devices.
Case presentation
Case 1
An elderly patient presented with right-sided weakness and aphasia, and was seen by the stroke neurology team and found to have a National Institutes of Health Stroke Scale (NIHSS) score of 17. CT on admission showed early ischemic signs in the left basal ganglia and insular cortex, and a CT angiogram showed an occlusion of the left terminal internal carotid artery (ICA).
Under conscious sedation, an 8 Fr balloon guide catheter was navigated into the aortic arch via the conventional transfemoral access. However, the navigation above the aortic arch was extremely challenging owing to the extremely tortuous left common carotid artery as well as a bovine aortic arch (figure 1A). Access to the left carotid artery was not possible after multiple attempts for 10 min. In order to reach the lesion as soon as possible, while another physician continued to make attempts to gain access via the transfemoral approach, a 6 Fr sheath was simultaneously inserted into the right brachial artery and a 6 Fr Envoy Guiding Catheter (Codman Neurovascular/Codman and Shurtleff, Inc, Raynham, Massachusetts, USA) was advanced easily to the left common carotid artery (figure 1B).
Case 1: (A) The left common carotid artery is severely tortuous, and there is a bovine aortic arch variant (black arrow). (B) The guiding catheter is advanced to the left common carotid artery via a transbrachial approach (black arrowhead). (C and D) The terminal segment of the left internal carotid artery is occluded. (E) The stent retriever is passed and deployed distal to the thrombus in the intracranial artery (white arrowhead). (F) The left internal carotid artery is successfully recanalized. (G) The clot attaches to the stent retriever (white arrow).
There was evidence of a long, occlusive lesion at the terminal left ICA extending into the distal M1 segment, with no contrast opacification beyond this level (figure 1C, D). A Stryker Trevo XP Retrieval System (Concentric Medical, Fremont, California, USA) and a Solitaire 2 Revascularization Device (Covidien/ev3 Endovascular, Inc, Plymouth, Minnesota, USA) were used to retrieve the thrombus (figure 1E). The left ICA and middle cerebral artery (MCA) were successfully recanalized after four retrieval attempts (figure 1F). Some of the clots were attached to the stent and some were found in the aspiration syringe (figure 1G). The 6 Fr Envoy via the right brachial sheath was stable throughout the procedure and provided enough support to advance the microcatheter to the lesion. There was no immediate complication. The right brachial sheath was then removed and manual compression for 15 min resulted in good hemostasis.
Case 2
An elderly patient with a history of atrial fibrillation discontinued his anticoagulation therapy and underwent aortobifemoral bypass surgery. He had a sudden onset of vomiting and left-sided paralysis several hours after the surgery. A CT angiogram with perfusion showed a right MCA occlusion and an extensive area of tissue at risk in the right MCA territory. The initial NIHSS score was 20. The patient had recently undergone bifemoral bypass surgery and conventional transfemoral access was therefore not possible. Under conscious sedation, a 5 Fr sheath was placed into the right brachial artery. A Simmons 2 catheter was advanced to the right carotid artery, and exchanged for a ReFlex/Navien 0.58 distal catheter (Reverse Medical/Covidien, Irvine, California, USA) and a Marksman microcatheter (Covidien, Irvine, California, USA) (figure 2A, B) combination over an X-Celerator 14 exchange wire (Covidien). The tip of the microcatheter was advanced into the occluded M1 branch. The first retrieval attempt was made with a 4 mm×20 mm Solitaire FR revascularization device (Covidien) (figure 3B, C) and the second with a 6 mm×20 mm Solitaire device (figure 2D, E). These attempts resulted in complete recanalization of the branch, with normal antegrade flow within the angular and temporo-occipital branches (figure 2F). The Navien 0.58 without any guide catheter provided us with adequate support to perform the clot retrieval procedure in the M1 and M2 segments. Hemostasis was achieved with manual compression for 15 min. There were no complications.
Case 2: (A) Catheterization to the right common carotid artery is performed via a transbrachial approach. (B) The M2 branch of the right middle cerebral artery is completely occluded. (C, D, and E) The stent retriever is passed and deployed. The tip of the stent is shown (white arrowhead). (F) The occluded M2 branch is recanalized.
Case 3 (A) Catheterization to the right common carotid artery via the transbrachial approach. (B) The M2 of the right middle cerebral artery is occluded completely (white arrowhead). (C) Intra-arterial tissue plasminogen activator is injected from the tip of microcatheter. (D and E) The occluded M2 branch is partially recanalized (black arrowheads).
Case 3
A middle-aged patient was transferred from an outside hospital after unsuccessful cardiac catheterization because of chronic total occlusion of bilateral iliac arteries. A modified Allen test in both wrists had failed in this patient. Several hours after the cardiac catheterization procedure, he had suddenly developed a left-sided facial palsy, right gaze deviation, left-sided weakness, and inability to communicate or follow commands. The initial NIHSS score was 24. CT of the brain showed a punctate hyperdense focus within the right Sylvian fissure suggesting a possible clot. There was no radiographic evidence of early infarction. Subsequently, the patient received intravenous tissue plasminogen activator (tPA); however, no clinical improvement was seen. Therefore, a decision was made to perform mechanical clot retrieval. Because of the known history of bilateral iliac occlusions and the failed Allen tests, brachial access was chosen for the mechanical intervention. A 5 Fr sheath was inserted into the right brachial artery and a 5 Fr Simmons 2 catheter was initially advanced into the right common carotid artery over a 0.035 angle guidewire. Then it was exchanged for a distal access catheter DAC 044 (Stryker/Concentric Medical, Inc, Mountain View, California, USA) and Echelon 14 microcatheter (Covidien/ev3 Endovascular) combination over an X-Celerator 14 exchange wire (Covidien). Right ICA angiograms showed an abrupt cut-off point within the posterior division of the M2 branch of the right MCA (figure 3B,C). An Echelon 14 microcatheter was carefully advanced into the occlusive lesion, and 6 mg of tPA was infused over a period of about 18 min (figure 3D). Mechanical thrombectomy was not performed because of the small size of the occluded vessel. Immediately after tPA infusion, the micro-guidewire was used to macerate the clot. The right ICA angiogram showed partial recanalization (figure 3E). The catheters were then removed and hemostasis was achieved with manual compression over the right brachial puncture.
Discussion
Recently introduced thrombectomy devices for acute ischemic stroke, including stent retrievers, enable higher recanalization rates and established procedural safety as shown by multiple single-arm prospective clinical trials.1–3 A conventional transfemoral arterial approach is commonly used in those clinical trials and also in routine clinical practice. Although the femoral approach remains the standard, there are rare occasions that femoral arterial puncture is physically impossible or unsafe such as in cases 2 and 3. Although it is rare, certain tortuous anatomies in the aorta and cervical arteries can make the femoral approach extremely challenging or make it impossible to reach the intracranial lesion.8 Since in acute ischemic stroke, shorter endovascular procedural times are associated with better outcomes, the use of an alternative access that could enable swifter access to the lesion than the conventional femoral approach may be of benefit in selected cases, as in case 1.4 ,9
Transbrachial approaches to coronary, as well as cerebral and carotid, angiography and intervention have been developed to enhance patient comfort and to reduce complications occurring at the puncture site. Treatment of some cerebrovascular diseases using this approach has been documented.5–7 If transfemoral access appears difficult, alternative approaches such as transbrachial access and direct puncture of the carotid artery can be explored. To the best of our knowledge, this is the first report describing the practicality of the transbrachial approach in the era of the stent retriever.
Once the guiding catheter is passed to the carotid artery, it is important to determine if a stent retriever can be passed to an intracranial vessel. We use distally accessible catheters such as the Navien (Covidien, eV3 Neurovascular, Irvine, California, USA), ReFlex (Reverse Medical) and DAC (Concentric Medical), which can be efficiently passed. The DAC has been used successfully with other revascularization devices in ischemic stroke previously.10 If these catheters can be passed to the petrous portion of the carotid artery, a stent retriever will be able to capture the clot, and by guiding the intermediate catheters into the intracranial vessels, the clot can be aspirated. A balloon guiding catheter might be an alternative but can kink or fall into the aorta during a procedure in which the angle of the origin of the common carotid artery is steep.6
Direct carotid artery puncture can provide an alternative to transfemoral artery access in cases of stroke with difficult anatomy.11 When direct carotid puncture is performed, attention should be given to achieving hemostasis at the puncture site, manual compression being the most common method.12–14 Closure of the carotid artery using devices such as the Angio-Seal (St Jude Medical, St Paul, Minnesota, USA) and StarClose SE Vascular Closure System (Abbott Vascular, Abbott Park, Illinois, USA) has been reported.11 ,14 With any closure method, there is a risk of choking and low perfusion of the carotid artery should a large hematoma develop in the neck. In cases of direct carotid puncture, the operator at the neck side may obstruct the visual field of the operator at the femoral side.
The transbrachial approach also has some disadvantages, including difficulty in cases in which a vessel is tortuous or there is a thoracic aortic aneurysm, limited selection of devices because of the smaller size of the brachial artery, and risk of occlusion of the brachial artery by hematoma or dissection at the puncture site.15 Additionally, if the subclavian artery has a steno-occlusive lesion, it may be difficult to access the common carotid artery.
Conclusions
Transbrachial endovascular recanalization for acute ischemic stroke, including the use of new devices, is feasible and may provide an alternative strategy for treatment of stroke in specific cases.
References
Footnotes
Contributors Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: MO, ST, LKA, MLT. Drafting the work or revising it critically for important intellectual content: DL, GRD. Final approval of the version to be published: JS, GRD. Agreement 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: ST, DL, GRD.
Competing interests None.
Ethics approval This study was approved by the Institutional Review Board of the institution and was conducted in compliance with the Health Information Portability and Accountability Act.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement We collected the data from the electric chart system of Ronald Reagan Medical Center of UCLA.