Transradial Approach for Complex Anterior and Posterior Circulation Interventions: Technical Nuances and Feasibility of Using Current Devices

2018 ◽  
Vol 17 (3) ◽  
pp. 293-302 ◽  
Author(s):  
Brian M Snelling ◽  
Samir Sur ◽  
Sumedh S Shah ◽  
Justin Caplan ◽  
Priyank Khandelwal ◽  
...  
Keyword(s):  
Posterior Circulation ◽  
Single Institution ◽  
Access Site ◽  
Anterior Circulation ◽  
Transfemoral Approach ◽  
Operator Experience ◽  
Balloon Test Occlusion ◽  
Increased Risk ◽  
Institutional Experience ◽  
Neurointerventional Procedures

AbstractBACKGROUNDDespite several studies analyzing the safety of transradial access (TRA) for neurointervention compared to transfemoral approach (TFA), neurointerventionalists are apprehensive about implementing TRA. From our positive institutional experience, we now utilize TRA first line for a majority of our cases. Here, we present our single-institution experience.OBJECTIVETo determine safety and feasibility of TRA for neurointervention.METHODSThrough retrospective review of patients receiving TRA for anterior and posterior circulation cerebrovascular interventions at our institution between December 2015 and January 2018, we present our experience regarding this transition, while focusing on technique, complications, feasibility, indications, and limitations.RESULTSOne hundred five procedures were performed on 92 patients (anterior circulation: 77%; posterior circulation: 23%). Radial artery access was achieved in all patients. Twenty-nine cases constituted mechanical thrombectomy, 33 cases represented intracranial aneurysms treatments, and 33 cases included interventions like angioplasty, balloon test occlusion, chemotherapy delivery, and thrombolysis. TRA was used as second-line access to TFA in 5 instances due to aortic arch anomalies and atherosclerotic disease. Minor access-site complications were seen in 2.85% of patients. Ten procedures (9.0%) could not be completed with TRA, with crossover to TFA occurring in 7 cases.CONCLUSIONTRA is safe and feasible for the majority of neurointerventional procedures and provides decreased risk of major access-site complications compared to TFA. Perceived limitations of TRA can likely be eliminated via operator experience and engineering ingenuity; thus, there is a role for TRA for neurointervention, especially in patients with increased risk of access-site complications from TFA.

scholarly journals Access-Site Complications in Transfemoral Neuroendovascular Procedures: A Systematic Review of Incidence Rates and Management Strategies

2020 ◽  
Vol 19 (4) ◽  
pp. 353-363 ◽  
Author(s):  
Mazen Oneissi ◽  
Ahmad Sweid ◽  
Stavropoula Tjoumakaris ◽  
David Hasan ◽  
M Reid Gooch ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Femoral Artery ◽  
Management Strategies ◽  
Femoral Nerve ◽  
Incidence Rates ◽  
Common Complication ◽  
Access Site ◽  
Transfemoral Approach ◽  
Femoral Access ◽  
Neurointerventional Procedures

Abstract BACKGROUND The femoral artery is the most common access route for cerebral angiography and neurointerventional procedures. Complications of the transfemoral approach include groin hemorrhages and hematomas, retroperitoneal hematomas, pseudoaneurysms, arteriovenous fistulas, peripheral artery occlusions, femoral nerve injuries, and access-site infections. Incidence rates vary among different randomized and nonrandomized trials, and the literature lacks a comprehensive review of this subject. OBJECTIVE To gather data from 16 randomized clinical trials (RCT) and 17 nonrandomized cohort studies regarding femoral access-site complications for a review paper. We also briefly discuss management strategies for these complications based on the most recent literature. METHODS A PubMed indexed search for all neuroendovascular clinical trials, retrospective studies, and prospective studies that reported femoral artery access-site complications in neurointerventional procedures. RESULTS The overall access-site complication rate in RCTs is 5.13%, while in in non-RCTs, the rate is 2.78%. The most common complication in both groups is groin hematoma followed by access-site hemorrhage and femoral pseudoaneurysm. On the other hand, wound infection was the least common complication. CONCLUSION The transfemoral approach in neuroendovascular procedures holds risk for several complications. This review will allow further studies to compare access-site complications between the transfemoral approach and other alternative access sites, mainly the transradial approach, which is gaining a lot of interest nowadays.

scholarly journals Increased risk for posterior circulation ischaemia in patients with vertebral artery hypoplasia: A systematic review and meta-analysis

2017 ◽  
Vol 2 (2) ◽  
pp. 171-177
Author(s):  
Aristeidis H Katsanos ◽  
Sotirios Giannopoulos
Keyword(s):  
Systematic Review ◽  
Observational Study ◽  
Vertebral Artery ◽  
Risk Ratio ◽  
Meta Analysis ◽  
Posterior Circulation ◽  
Anterior Circulation ◽  
Study Protocols ◽  
Increased Risk ◽  
Vertebral Artery Hypoplasia

Introduction Although several study protocols reported that vertebral artery hypoplasia can predispose to posterior circulation ischaemia, the role of vertebral artery hypoplasia in the risk of posterior circulation ischaemia still remains controversial. The aim of the present meta-analysis was to investigate the association of vertebral artery hypoplasia and posterior circulation ischaemia. Patients and methods We performed a systematic review and random effects meta-analysis of all eligible observational study protocols reporting prevalence rates of vertebral artery hypoplasia in patients with anterior circulation ischaemia and posterior circulation ischaemia. Results We identified eight study protocols including a total of 3875 acute ischemic stroke patients (mean age: 64.2 years, 61.3% males) and reporting a pooled prevalence of vertebral artery hypoplasia 18.6% (95%CI: 10.8–30.0%). In the overall analysis, a significantly higher probability of vertebral artery hypoplasia presence was found in posterior circulation ischaemia patients compared to patients with anterior circulation ischaemia (risk ratio = 2.12, 95%CI: 1.60–2.82, p < 0.001). In the subsequent sensitivity analysis, vertebral artery hypoplasia was again found to be significantly more prevalent in patients with posterior circulation ischaemia compared to anterior circulation ischaemia (risk ratio = 1.81, 95%CI: 1.58–2.06, p < 0.001), with no evidence of heterogeneity (I2 = 0%, p for Cochran Q = 0.55) between included studies. Discussion The present report is a meta-analysis of retrospective observational study protocols, with all the inherent limitations of included studies. The heterogeneity on the reported rates of vertebral artery hypoplasia could be attributed to differences in population age, sex, race, imaging protocols and vertebral artery hypoplasia definition between included studies. Conclusion Our meta-analysis provides further evidence for a possible causal relationship between vertebral artery hypoplasia and cryptogenic posterior circulation ischaemia, an association which undoubtedly deserves further investigation in future prospective study protocols.

scholarly journals Transradial approach for mechanical thrombectomy in anterior circulation large-vessel occlusion

2017 ◽  
Vol 42 (4) ◽  
pp. E13 ◽  
Author(s):  
Samir Sur ◽  
Brian Snelling ◽  
Priyank Khandelwal ◽  
Justin M. Caplan ◽  
Eric C. Peterson ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Access Site ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Transradial Approach ◽  
First Pass ◽  
Institutional Experience ◽  
Stent Retrievers ◽  
The Right

OBJECTIVE The goals of this study were to describe the authors' recent institutional experience with the transradial approach to anterior circulation large-vessel occlusions (LVOs) in acute ischemic stroke patients and to report its technical feasibility. METHODS The authors reviewed their institutional database to identify patients who underwent mechanical thrombectomy via a transradial approach over the 2 previous years, encompassing their experience using modern techniques including stent retrievers. RESULTS Eleven patients were identified. In 8 (72%) of these patients the right radial artery was chosen as the primary access site. In the remaining patients, transfemoral access was initially attempted. Revascularization (modified Treatment in Cerebral Ischemia [mTICI] score ≥ 2b) was achieved in 10 (91%) of 11 cases. The average time to first pass with the stent retriever was 64 minutes. No access-related complications occurred. CONCLUSIONS Transradial access for mechanical thrombectomy in anterior circulation LVOs is safe and feasible. Further comparative studies are needed to determine criteria for selecting the transradial approach in this setting.

Feasibility of repeat transradial access for neuroendovascular procedures

2019 ◽  
Vol 12 (4) ◽  
pp. 431-434 ◽  
Author(s):  
Stephanie H Chen ◽  
Marie-Christine Brunet ◽  
Samir Sur ◽  
Dileep R Yavagal ◽  
Robert M Starke ◽  
...  
Keyword(s):  
Radial Artery ◽  
Artery Occlusion ◽  
Access Site ◽  
Transfemoral Approach ◽  
Radial Access ◽  
Artery Segment ◽  
Clinical Consequences ◽  
Radial Artery Occlusion ◽  
Neurointerventional Procedures ◽  
Repeat Procedures

IntroductionTransradial artery access (TRA) for cerebrovascular angiography is increasing due to decreased access site complications and overwhelming patient preference. While interventional cardiologists have reported up to 10 successive TRA procedures via the same radial access site, this is the first study examining successive use of the same artery for repeat procedures in neurointerventional procedures.1 MethodsWe reviewed our prospective institutional database for all patients who underwent a transradial neurointerventional procedure between 2015 and 2019. Index procedures were defined as procedures performed via TRA after which there was a second TRA procedure attempted. Reasons for conversion to a transfemoral approach (TFA) for subsequent procedures were identified.Results104 patients underwent 237 procedures (230 TRA, 7 TFA). 97 patients underwent ≥2 TRA procedures, 20 patients >3, four patients >4, three patients >5, and two patients >6 TRA procedures. The success rate was 94.7% (126/133) with 52% (66/126) of successive procedures performed via the same radial access site (snuffbox vs antebrachial) while the alternate radial artery segment was used for access in 48% (60/126) of subsequent procedures. There were seven (5.3%) cases requiring crossover to TFA, six cases for radial artery occlusion (RAO) and one for radial artery narrowing.ConclusionSuccessive TRA is both technically feasible and safe for neuroendovascular procedures in up to six procedures. The low failure rate (5.3%) was primarily due to RAO. Thus, even without clinical consequences, strategies to minimize RAO should be optimized for patients to continue to benefit from TRA in future procedures.

scholarly journals Plaques in the carotid artery and risk of cerebral infarcts in the elderly; The Rotterdam Study

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 363-363
Author(s):  
Monika Hollander ◽  
Michiel L Bots ◽  
Jacqueline Cm Witteman ◽  
Peter J Koudstaal ◽  
Diederick E Grobbee ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Cox Regression ◽  
The Elderly ◽  
Posterior Circulation ◽  
Rotterdam Study ◽  
Cerebral Infarcts ◽  
Anterior Circulation ◽  
Plaque Score ◽  
Carotid Plaques ◽  
Increased Risk

P132 Background Presence of carotid plaques is associated with increased risk of cerebral infarcts. Whether they directly cause a stroke through embolism or merely are indicators of generalised atherosclerosis is not extensively investigated. We studied this by assessing the association between plaques at different carotid segments and risk of subtypes of cerebral infarcts. Methods Our study is based on 5444 subjects from the Rotterdam Study, a population based cohort study. Subjects were free from previous stroke. Presence of plaques was assessed in 3 segments of both carotid arteries at baseline (1990–1993). A total plaque score reflected the number of locations with plaques (range 0–6). Follow up for stroke was complete until December 31 1997. We calculated the risk of severe plaques (score 5–6) compared to absence of plaques (score 0) by Cox regression, adjusting for age and gender. Furthermore, we analysed the risk of unilateral and bilateral plaques compared to absence of plaques at different segments of the carotid artery. Relative risks (95% CI) are given for subtypes of cerebral infarct. Results In total 224 strokes occurred of whom 130 were ischemic. Severe plaques were present in 7% of the population and associated with an increased risk of lacunar and anterior circulation infarcts (RR 12.0 (2.0–70) and 4.5 (1.6–12.3), respectively). After exclusion of infarcts of presumed cardio-embolic cause the relative risk of anterior circulation infarcts was 9.4 (2.5–35.7). The risk for bilateral plaques was higher than for unilateral plaques when we analysed carotid segments separately. We found no association between severe plaques and risk of posterior circulation infarcts. Conclusion Carotid plaques are associated with increased risk of lacunar and anterior circulation infarcts. Associations were stronger with increasing number of plaques. This suggests that carotid plaques are markers of atherosclerosis on large and small vessel level. Since we found no association with posterior circulation infarcts it seems likely that at least part of the effect is through thrombo-embolism.

Transradial cerebral angiography: techniques and outcomes

2018 ◽  
Vol 10 (9) ◽  
pp. 874-881 ◽  
Author(s):  
Brian M Snelling ◽  
Samir Sur ◽  
Sumedh S Shah ◽  
Priyank Khandelwal ◽  
Justin Caplan ◽  
...  
Keyword(s):  
Cerebral Angiography ◽  
Marked Improvement ◽  
Retrospective Studies ◽  
Mechanical Thrombectomy ◽  
Technical Success ◽  
Stroke Patients ◽  
Single Institution ◽  
Institutional Experience ◽  
Neurointerventional Procedures

BackgroundDespite several retrospective studies analyzing the safety and efficacy of transradial access (TRA) versus transfemoral access (TFA) for cerebral angiography, this transition for neurointerventional procedures has been gradual. Nonetheless, based on our positive initial institutional experience with TRA for mechanical thrombectomy in acute ischemic stroke patients, we have started transitioning more of our cerebral angiography cases to TRA. Here we present our single institution experience.MethodsWe performed a retrospective review of patients receiving TRA cerebral angiography at our institution between January 2016 and February 2017. We present our experience transitioning from TFA to TRA, including our criteria for patient selection, technical nuances, patient experience, complications, and operator learning curve.ResultsWe included 148 angiograms performed in 141 people by one of four operators. No major complications were observed, and the technical success of the procedures was consistent with those of TFA. Marked improvement in operator efficiency was achieved in a short number of cases during this transition when looking at operator proficiency as a function of angiograms performed and days of exposure to TRA (4.3 vs 3.6 min/vessel, P<0.05).ConclusionsSafety and efficiency can be preserved while transitioning to TRA. While further investigation is necessary to support transition to TRA, these findings should call for a re-evaluation of the role of TRA in catheter cerebral angiography.

scholarly journals Ulnar Artery Access: A Nontraditional Access Site for Diagnostic Cerebral Angiography and Neurointervention: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Rimal H Dossani ◽  
Muhammad Waqas ◽  
Justin M Cappuzzo ◽  
Ashish Sonig ◽  
Faisal Almayman ◽  
...  
Keyword(s):  
Radial Artery ◽  
Cerebral Angiography ◽  
Video Recording ◽  
Ulnar Artery ◽  
Lateral Approach ◽  
Access Site ◽  
Transfemoral Approach ◽  
Radial Access ◽  
Institutional Review ◽  
Neurointerventional Procedures

Abstract Transfemoral access has long been the main access site for cerebral angiography and neurointerventional procedures. Radial access is accepted as an alternative to the traditional transfemoral approach. Ulnar access may be undertaken if the radial artery is occluded or small caliber, or when radial artery preservation is needed. The safety and feasibility of ulnar access for neuroangiographic procedures has been demonstrated.1-3 In this operative video, we demonstrate ulnar artery access in a patient in whom radial artery preservation was desired. We further elaborate on the technical nuances of this access. This nontraditional access site offers the same advantages as radial access, avoiding the need to switch to femoral artery access. A preoperative Allen's test is not necessary. Ultrasound imaging is used to aid in the identification and successful puncture of the ulnar artery. A medial to lateral approach for ulnar artery puncture is advised to avoid injury to the ulnar nerve. Careful application of wrist closure bands avoids hematoma accumulation.  The patient gave informed consent for the procedure and video recording. Institutional review board approval was deemed unnecessary.  Video. © University at Buffalo, May 2021. Used with permission.

Safety and efficacy of ticagrelor as single antiplatelet therapy in prevention of thromboembolic complications associated with the Pipeline Embolization Device (PED): multicenter experience

2020 ◽  
Vol 12 (11) ◽  
pp. 1113-1116 ◽  
Author(s):  
Mahmoud H Mohammaden ◽  
Stephen W English ◽  
Christopher J Stapleton ◽  
Eman Khedr ◽  
Ahmed Shoyb ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Intracranial Aneurysms ◽  
Posterior Circulation ◽  
Thromboembolic Complications ◽  
Anterior Circulation ◽  
Safety And Efficacy ◽  
Complex Aneurysm ◽  
Post Procedure ◽  
Systemic Side Effects ◽  
Ischemic Events

BackgroundFlow diversion (FD) is a common treatment modality for complex intracranial aneurysms. A major concern regarding the use of FD is thromboembolic events (TEE). There is debate surrounding the optimal antiplatelet regimen to prevent TEE. We aim to evaluate the safety and efficacy of ticagrelor as a single antiplatelet therapy (SAPT) for the prevention of TEE following FD for complex aneurysm treatment.MethodsA retrospective review of a prospectively maintained neuroendovascular database at three endovascular centers was performed. Patients were included if they had an intracranial aneurysm that was treated with FD between January 2018 and September 2019 and were treated with ticagrelor as SAPT. Primary outcomes included early (within 72 hours post-procedure) and late (within 6 months) ischemic events.ResultsA total of 24 patients (mean age 47.7 years) with 36 aneurysms were eligible for analysis, including 15 (62.5%) females. 14 (58.3%) patients presented with subarachnoid hemorrhage. 35 aneurysms arose from the anterior circulation and 1 from the posterior circulation. 23 aneurysms had a saccular morphology, whereas 7 were fusiform and 6 were blister. For the treatment of all 36 aneurysms, 30 procedures were performed with 32 FD devices. Procedural in-stent thrombosis occurred in 2 cases and was treated with intra-arterial tirofiban without complications. Aneurysm re-bleeding was reported in 1 (4.2%) patient. There were no reported early or late TEE. Three patients discontinued ticagrelor due to systemic side effects.ConclusionTicagrelor is a safe and effective SAPT for the prevention of TEE after FD. Large multicenter prospective studies are warranted to validate our findings.

scholarly journals Intravenous thrombolysis outcome in posterior vs anterior circulation stroke in a tertiary stroke center in Egypt

2021 ◽  
Vol 57 (1) ◽  
Author(s):  
Nourhan Abdelmohsen Taha ◽  
Hala El Khawas ◽  
Mohamed Amir Tork ◽  
Tamer M. Roushdy
Keyword(s):  
Intravenous Thrombolysis ◽  
Posterior Circulation ◽  
University Hospitals ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Time Points ◽  
Posterior Circulation Stroke ◽  
First Line Therapy ◽  
Insignificant Difference ◽  
Stroke Center

Abstract Background Intravenous thrombolysis (IVT) with alteplase is the first-line therapy for acute ischemic anterior and posterior circulation strokes (ACS and PCS). Knowledge about safety and efficacy of IVT in posterior circulation stroke is deficient as most of the Egyptian studies either assessed IVT outcome in comparison to conservative therapy or its outcome in anterior circulation stroke only. Therefore, our aim was to compare the relative frequency and outcome after intravenous thrombolysis in anterior versus posterior circulation stroke patients presenting to stroke centers of Ain Shams University hospitals (ASUH). Results A total of 238 anterior circulation stroke and 61 posterior circulation strokes were enrolled, onset-to-door and door-to-needle time were statistically insignificant. NIHSS showed comparable difference at all time points despite higher scores along anterior circulation stroke; 90-day modified Rankin Scale (mRS) showed significant improvement in both groups from mRS >2 to ≤2 with a better percentage along posterior circulation stroke patients. There was insignificant difference for either incidence of death or intracranial hemorrhage (ICH) between the two groups. Conclusion IVT significantly reduced NIHSS for both anterior and posterior circulation stroke along different studied time points. Meanwhile, a higher percentage of patients with posterior circulation stroke had a better mRS outcome at 90 days.

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