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. 2018 Nov;10(2):11-14.

Difficult Vascular Access Anatomy Associated with Decreased Success of Revascularization in Emergent Thrombectomy

Travis M Dumont  1 , Robert W Bina  1
Affiliations

Difficult Vascular Access Anatomy Associated with Decreased Success of Revascularization in Emergent Thrombectomy

Travis M Dumont et al. J Vasc Interv Neurol. 2018 Nov.

Abstract

Background: Thrombectomy has become established as a successful treatment strategy for ischemic stroke, and consequently, more patients are undergoing this procedure. Due to comorbid conditions, chronic disease states, and advanced age, many patients have anatomy which complicates revascularization, specifically difficult aortic arch anatomy, or tortuous common and internal artery anatomy, or both.

Methods: In the present study, these unfavorable anatomic parameters were analyzed for 53 patients undergoing acute thrombectomy for ischemic stroke. Statistical analysis was performed and the outcome TICI scores were compared. 26 of the patients analyzed had features of difficult femoral access.

Results: Difficult arch anatomy was associated with unsuccessful revascularization (p = 0.03, Fisher's exact) with only 53% of patients with this feature having favorable TICI scores. Difficult common carotid access was also associated with unsuccessful revascularization (p = 0.004, Fisher's exact) with 38% success. There was a trend toward significance for unsuccessful revascularization for difficult internal carotid artery access (p = 0.06, Fisher's exact).

Conclusion: Any combination of the aforementioned anatomic parameters was associated with the decreased success of treatment which was an independent predictor in multivariate analysis (p = 0.009). As difficult access anatomy is commonly encountered in patients undergoing emergent thrombectomy, it is important for the treating physician to be prepared and to adapt access strategies to increase the likelihood of successful revascularization.

Keywords: Thrombectomy; difficult access; ischemic stroke; revascularization.

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Figures

Figure 1
Figure 1. Case 9 presented with right M1 occlusion. Despite difficult access with Type III arch, common carotid acute angle turn, and internal carotid artery acute angle turn, successful thrombectomy was performed. This image represents postthrombectomy magnetic resonance angiography, displaying revascularized right middle cerebral artery.
Figure 2
Figure 2. Case 47 presented with left middle cerebral artery occlusion. With the bovine arch configuration, acute angle turn in the common carotid artery, and 360° loop in the cervical internal carotid artery, insufficient access was obtained and a microcatheter was unable to be placed for stent-retriever or aspiration thrombectomy. The surgery was unsuccessful.
Figure 3
Figure 3. Two or more unfavorable vascular access features are associated with lower revascularization rates in emergent large vessel occlusion.
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