J Cerebrovasc Endovasc Neurosurg.  2023 Dec;25(4):429-433. 10.7461/jcen.2023.E2022.10.012.

Ulnar artery access for intracranial mechanical thrombectomy procedure: A salvage option after failed trans-femoral and trans-radial access

• Manzoor MU
• Alrashed AA
• Almulhim IA
• Alqahtani S
• Senani FA

• KMID: 2549448
• DOI: http://doi.org/10.7461/jcen.2023.E2022.10.012

Abstract

84 years old gentle man with past medical history of hypertension and diabetes presented with sudden onset right sided weakness and aphasia for two hours. Initial neurological assessment revealed National Institute of Health Stroke Scale (NIHSS) 17. Computed tomography (CT) scan demonstrated minimal early ischemic changes along left insular cortex with occlusion of left middle cerebral artery (MCA). Based on clinical and imaging findings, decision was made to perform mechanical thrombectomy procedure. Initially, right common femoral artery approach was utilized. However, due to unfavorable type-III bovine arch, left internal carotid artery could not be engaged via this approach. Subsequently, access was switched to right radial artery. Angiogram revealed small caliber radial artery, with larger caliber ulnar artery. Attempt was made to advance the guide catheter through the radial artery, however significant vasospasm was encountered. Subsequently, ulnar artery was accessed and successful thrombolysis in cerebral infarction (TICI) III left MCA reperfusion was achieved with a single pass of mechanical thrombectomy via this approach. Post procedure neurological examination demonstrated significant clinical improvement. Doppler ultrasound 48 hours after the procedure demonstrated patent flow in radial and ulnar arteries with no evidence of dissection.

Keyword

Ulnar artery access; Radial artery; Mechanical thrombectomy; Acute stroke intervention; Interventional neuroradiology

Figure

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  Fig. 1. (A) Coronal computed tomography angiogram at aortic arch level, demonstrating a bovine arch. (B) Simmons II catheter is advanced in the left common carotid artery. (C) Radial artery angiogram demonstrates vasospasm along radial artery (white arrow) and larger caliber ulnar artery (white asterisk). (D) Angiogram through the Simmons II catheter placed via right ulnar artery approach, demonstrating bovine arch. (E) Left internal carotid artery angiogram demonstrating proximal M2 superior division occlusion (white arrow). (F) Post mechanical thrombectomy angiogram shows complete reperfusion of the left middle cerebral artery (MCA) territory.

Reference

1. Alverne FJAM, Lima FO, Rocha FA, Bandeira DA, Lucena AF, Silva HC, et al. Unfavorable vascular anatomy during endovascular treatment of stroke: challenges and bailout strategies. J Stroke. 2020; May. 22(2):185–202.

2. Chen SH, Snelling BM, Sur S, Shah SS, McCarthy DJ, Luther E, et al. Transradial versus transfemoral access for anterior circulation mechanical thrombectomy: comparison of technical and clinical outcomes. J Neurointerv Surg. 2019; Sep. 11(9):874–8.

3. Cho HW, Jun HS. Can transradial mechanical thrombectomy be an alternative in case of impossible transfemoral approach for mechanical thrombectomy? A single center’s experience. J Korean Neurosurg Soc. 2021; Jan. 64(1):60–8.

4. Cord BJ, Kodali S, Strander S, Silverman A, Wang A, Chouairi F, et al. Direct carotid puncture for mechanical thrombectomy in acute ischemic stroke patients with prohibitive vascular access. J Neurosurg. 2020; Aug. 1–11.

5. Dumas V, Kaesmacher J, Ognard J, Forestier G, Dargazanli C, Janot K, et al. Carotid artery direct access for mechanical thrombectomy: the Carotid Artery Puncture Evaluation (CARE) study. J Neurointerv Surg. 2022; Dec. 14(12):1180–5.

6. Goyal M, Menon BK, van Zwam WH, Dippel DWJ, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016; Apr. 387(10029):1723–31.

7. Lu CJ, Lin YH, Chu HJ, Tang SC, Lee CW. Safety and efficacy of the transbrachial approach for endovascular thrombectomy in patients with acute large vessel occlusion stroke. J Formos Med Assoc. 2021; Jan. 120(1 Pt 3):705–12.

8. Manzoor MU, Almulhim IA, Alrashed AA, Alturki A, Alghabban FA, Al-Qahtani SM. Common ground, different path: ulnar artery access for interventional neurovascular procedures. Interv Neuroradiol. 2022; Aug. 28(4):463–8.

9. Manzoor MU, Alrashed AA, Almulhim IA, Althubait S, Al-Qahtani SM, Al-Senani F, et al. Exploring the path less traveled: distal radial access for diagnostic and interventional neuroradiology procedures. J Clin Neurosci. 2021; Aug. 90:279–83.

10. Maud A, Moreno JH, Sheriff FG, Chaudry MR, Gupta V, Khatri R, et al. Transradial access results in faster recanalization in left anterior circulation stroke with bovine arch anatomy. Stroke: Vascular and Interventional Neurology. 2022; May. 2(4):e000243.

11. Miszczuk M, Bauknecht HC, Kleine JF, Liebig T, Bohner G, Siebert E. Direct puncture of the carotid artery as a bailout vascular access technique for mechanical thrombectomy in acute ischemic stroke-the revival of an old technique in a modern setting. Neuroradiology. 2021; Feb. 63(2):275–83.

12. Ribo M, Flores A, Rubiera M, Pagola J, Mendonca N, Rodriguez-Luna D, et al. Difficult catheter access to the occluded vessel during endovascular treatment of acute ischemic stroke is associated with worse clinical outcome. J Neurointerv Surg. 2013; May. 5 Suppl 1:i70–3.

13. Snelling BM, Sur S, Shah SS, Chen S, Menaker SA, McCarthy DJ, et al. Unfavorable vascular anatomy is associated with increased revascularization time and worse outcome in anterior circulation thrombectomy. World Neurosurg. 2018; Dec. 120:e976–83.

14. Turc G, Bhogal P, Fischer U, Khatri P, Lobotesis K, Mazighi M, et al. European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke. J Neurointerv Surg. 2019; Feb. neurintsurg-2018-014569.

15. Yan Chan JC, Edward Chu YL, Wei Cheung IH, On Tsang AC, Lau KK, Lee R. Direct carotid puncture for mechanical thrombectomy in acute ischemic stroke: literature review and a single-center experience. World Neurosurg. 2022; Jul. 163:e301–9.