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  • Transradial vs. Transfemoral Access for Mechanical Thrombectomy in Ischemic Stroke: A Single Center Prospective Analysis

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    Evan Luther MD; Brian Michael Snelling MD; Samir Sur MD; Stephanie H Chen MD; Sumedh Subodh Shah BS; David J McCarthy BS; Dileep Yavagal MD; Eric C. Peterson MD, MS; Robert M. Starke MD, MSc

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    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: Transradial access is frequently utilized in percutaneous coronary interventions and in recent years has increasingly been used as an alternative to transfemoral access for cerebrovascular interventions.1-12 It is especially valuable in patients where transfemoral access has failed or is not feasible.13-15 We present a single center, prospective analysis of patients who underwent mechanical thrombectomy for acute ischemic stroke via both transradial and transfemoral approaches.

    Methods: Patients with anterior circulation LVO treated with thrombectomy between 2015 and 2016 were reviewed from our prospective database. Initial analysis of the 95 patients treated with femoral approach and 21 treated with radial approach demonstrated significant differences in patient and disease specific characteristics. Blinded to outcome, 20 patients treated with radial and 60 patients treated with femoral approaches were matched in a 1:3 fashion based on patient age, gender, and aortic arch tortuosity. Multivariate conditional (matched) analysis was used to test covariates predictive of the following dependent variables: time to reperfusion, revascularization (= TICI 2B), and unfavorable outcome (mRS > 3).

    Results: Patients in the radial cohort were more likely to have significant carotid tortuosity. Access site was not predictive of revascularization (TICI2b-3) in multivariate analysis. Access site was also not predictive of time to reperfusion in multivariate analysis. M2 MCA location of the clot and tortuous anatomy were independent multivariate predictors of unfavorable outcome (mRS 4-6). Although patients in the radial cohort were significantly more likely to have tortuous anatomy, radial access site was not an independent predictor of unfavorable outcome.

    Conclusions: Radial access site can be used to achieve similar outcomes for mechanical thrombectomy. This suggests that transradial access is a viable option for access in the treatment of acute ischemic stroke in patients with unfavorable vascular anatomy.

    Patient Care: Transradial access for mechanical thrombectomy in acute ischemic stroke gives neurointerventionalists an alternative to the transfemoral approach which may be especially helpful in patient’s with limited femoral access or unfavorable aortic arch anatomy.

    Learning Objectives: Transradial access can be a viable option for the approach in mechanical thrombectomy for acute ischemic stroke.

    References: 1. Kiemeneij F, Laarman GJ, Odekerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the ACCESS study. J Am Coll Cardiol. 1997;29:1269-1275. 2. Philippe F, Larrazet F, Meziane T, et al. Comparison of transradial vs transfemoral approach in the treatment of acute myocardial infarction with primary angioplasty and abciximab. Catheter Cardiovasc Interv. 2004;61:67-73. 3. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. Am Heart J. 1999;138(3 Pt 1):430-436. 4. Hildick-Smith DJ, Walsh JT, Lowe MD, Shapiro LM, Petch MC. Transradial coronary angiography in patients with contraindications to the femoral approach: an analysis of 500 cases. Catheter Cardiovasc Interv. 2004;61:60-66. 5. Louvard Y, Lefèvre T, Allain A, Morice MC. Coronary angiography through the radial or the femoral approach: the CARAFE study. Catheter Cardiovasc Interv. 2001;52:181-187. 6. Louvard Y, Benamer H, Garot P, et al; the OCTOPLUS study group. Comparison of transradial and transfemoral approaches for coronary angiography and angioplasty in octogenarians (the OCTOPLUS study). Am J Cardiol. 2004;94:1177-1180. 7. Mann T. Stenting in acute coronary syndromes: a comparison of radial versus femoral access sites. J Am Coll Cardiol. 1998;32:572-576. 8. Slagboom T, Kiemeneij F, Laarman GJ, Wieken R, Odekerken D. Actual outpatient PTCA: results of the OUTCLAS pilot study. Catheter Cardiovasc Interv. 2001;53:204-208. 9. Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic evens: a systematic review and meta-analysis of randomized trials. Am Heart J. 2009;157:132-140. 10. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures: systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004;44:349-356. 11. Radial access for cerebrovascular procedures: Case report and technical note Sudhakar R Satti, Ansar Z Vance, Thinesh Sivapatham. Interventional Neuroradiology, Vol 22, Issue 2, pp. 227 – 235 12. Lorenzoni R, Roffi M. Transradial access for peripheral and cerebrovascular interventions. J Invasive Cardiol. 2013 Oct;25(10):529-36. 13. Haussen DC, Nogueira RG, DeSousa KG, et al. : Transradial access in acute ischemic stroke intervention. J Neurointerv Surg 8: 247–250, 2016 14. Samir Sur, MD, Brian Snelling, MD, Priyank Khandelwal, MD, Justin M. Caplan, MD, Eric C. Peterson, MD, Robert M. Starke, MD, and Dileep R. Yavagal, MD Transradial approach for mechanical thrombectomy in anterior circulation large-vessel occlusion. Neurosurg Focus 42 (4):E13, 2017 15. Achala S. Vagal, MD, MS; Pooja Khatri, MD, MSc; Joseph P. Broderick, MD; Thomas A. Tomsick, MD; Sharon D. Yeatts, PhD; Mark H. Eckman, MD, MS Time to Angiographic Reperfusion in Acute Ischemic Stroke Decision Analysis. Stroke. 2014;45:3625-3630 16. Altman DG: Practical statistics for medical research. Boca Raton, Fla.: Chapman & Hall/CRC, 1999

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