Can Transradial Mechanical Thrombectomy Be an Alternative in Case of Impossible Transfemoral Approach for Mechanical Thrombectomy? A Single Center's Experience

Abstract

Objective: Until recently, the transfemoral approach (TFA) was used as the primary method of arterial approach in acute ischemic stroke (AIS). However, TFA resulted in longer reperfusion times and worse outcomes in the mechanical thrombectomy (MT) of patients with complex aortic arches and significant carotid tortuosity. We found that the transradial approach (TRA) is a more favorable alternative approach for MT in such cases.

Methods: We performed a retrospective review of our institutional database to identify 202 patients who underwent MT for AIS between February 2015 and December 2019. Patient characteristics, cause of TFA failure, procedure time, intra-procedural complications, and outcomes were recorded.

Results: Eleven (5.4%) of 202 patients, who underwent MT for AIS, crossed over to TRA for recanalization, and eight (72%) of 11 achieved successful recanalization (≥modified Treatment in Cerebral Infarction 2b). The mean age (mean±standard deviation [median]) was 82.3±6.6 (76) years, and five of the 11 patients were male. The last seen normal to puncture time was 467.9±264.72 (264) minutes; baseline National Institutes of Health Stroke Scale score was 28.9±14.5 (16). Six (55%) of the 11 patients had right vertebrobasilar occlusions, and the remaining five (45%) had anterior circulation occlusive disease. The time from groin puncture to final recanalization time (overall procedural time) was 78.0±20.1 (62) minutes. The mean crossover time from TFA to TRA was 45.2±10.5 (41) minutes. The mean time from radial puncture to final recanalization was 33.8±10.5 (28) minutes. Distal thrombus migration events in previously unaffected territories occurred in 3/8 patients (37%). At 90 days, three patients (28%) had a favorable clinical outcome.

Conclusion: Although rare, failure of TFA has been known to occur during MT for AIS. Our results demonstrate that TRA may be an alternative option for AIS intervention for select patients with subsequent timely revascularization. However, the incidence of distal thrombus migration was high, and the first puncture to reperfusion time was prolonged because of the time taken for the crossover to TRA after failure of TFA. This study provides some evidence that the TRA may be a viable alternative option to the TFA for MT of AIS.

Keywords: Femoral artery; Ischemic stroke; Radiral artery; Thrombectomy.

Fig. 1.

An 83-year-old female with National Institutes of Health Stroke Scale 21. A : Magnetic resonance angiography showed the occlusion of basilar artery top (white arrow) with aortic arch “type III” and unfavorable right vertebral artery origin angle. B : Right subclavian artery anteroposterior (AP) angiography from transfemoral approach showed that guiding catheter could not advance to the target artery. C : Right subclavian artery AP from transradial aporoach via guiding catheter. D and E : A Solitaire stent retriever (4×30) was deployed and achieved modified Thrombolysis in Cerebral Infarction score 3 recanalization with a single pass. Her functional outcome was favorable (modified Rankin Scale 1) at 3 months.

Fig. 2.

An 80-year-old female with National Institutes of Health Stroke Scale 14. A : Computer tomographic angiography showed the occlusion of the right middle cerebral artery (MCA), M1 (white arrow) with aortic arch “type III” and severe tortuosity of the common and internal carotid artery. B : Unsubtracted anteroposterior (AP) angiography via transfemoral approach; the guiding catheter could not advance to the target artery. C : Right subclavian artery AP roadmap via the transradial approach via guiding catheter. D and E : A Solitaire stent retriever (5×30) was deployed and achieved complete recanalization of MCA with multiple passes. However, a migrated thrombus was seen in the right distal anterior cerebral artery (dACA). We did not perform mechanical thrombectomy for the distal thrombus migration on the right dACA. Her functional outcome was favorable (modified Rankin Scale 2) at 3 months.