Neurointervention.  2024 Mar;19(1):6-13. 10.5469/neuroint.2023.00500.

A “Radial Ready” Tricoaxial Setup for Anterior Circulation Mechanical Thrombectomy: Technical Aspects and Preliminary Results

• Molinaro S
• Russo R
• Mistretta F
• Risi G
• Gava UA
• Bergui M

• KMID: 2552874
• DOI: http://doi.org/10.5469/neuroint.2023.00500

Abstract

Purpose
Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). The choice of a transradial approach (TRA) for anterior circulation LVOs is still debatable; the use of a specific tricoaxial system could help mitigate numerous issues related to transradial MT.
Materials and Methods
From November 2022 to November 2023, 22 patients underwent TRA-MT for anterior circulation LVOs, both as first-line and rescue from transfemoral approach (TFA) failure, with the same triaxial setup consisting of a 7F introducer sheath, 7F guide catheter, and aspiration catheters ranging from 5.5F to 5F in relation to the occlusion site. Choice of thrombectomy technique was at operator discretion. Patients’ demographic data, clinical presentation, treatment details, complications, rate of crossover to TFA, successful revascularization (modified thrombolysis in cerebral infarction [mTICI] score ≥2b), and good clinical outcome at 3 months (modified Rankin scale [mRS] 0-2) were reported.
Results
Of 20 patients selected, 10 (50%) had occlusion of M1 segment of middle cerebral artery (MCA), 6 (30%) of internal carotid artery (ICA) terminus, and 4 (20%) with M2 MCA occlusions; 12/20 (60%) were right-sided occlusions and 8/20 (40%) were left-sided. The mean National Institutes of Health Stroke Scale score was 9.25 at admission. Successful revascularization to mTICI 2b-3 was achieved in 18/20 patients (90%). Intracranial complications were reported in 2 (10%) patients. Rate of radial artery occlusion at 24 hours was 10,6%; no access-site haemorrhagic complications were reported. Symptomatic intracranial hemorrhage occurred in 2 (10%) patients. mRS score 0-2 at 3 months was 50%.
Conclusion
The high technical effectiveness and good safety profile of this specific tricoaxial setup for TRA-MT in AIS, even for large proximal LVOs, could constitute a viable alternative to TFA-MT in selected cases.

Keyword

Stroke; Radial; Thrombectomy; Guide catheter; Sheath; Aspiration

Figure

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  Fig. 1. Successful TRA-MT in a septuagenarian with a National Institutes of Health Stroke Scale score of 23, Alberta Stroke Program Early CT score of 8, and a CT angiography demonstration of right ICA apex occlusion associated with relevant hypoplasia of right A1 tract of anterior cerebral artery (A, B). Type II aortic arch (C). Radial artery fluoroscopy run showed no forearm tortuosities (D). After a straightforward right common carotid artery catheterization (E) digital subtraction angiography in anteroposterior view, unsubtracted, confirmed the ICA apex occlusion (F) A RED 62 aspiration catheter in combination with a large diameter stent-retriever (Aperio 6×50 mm; Acandis) was used to perform thrombectomy (G), resulting in thrombolysis in cerebral infarction score 3 after a single passage (H). TRA, transradial approach; MT, mechanical thrombectomy; CT, computed tomography; ICA, internal carotid artery.

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  Fig. 2. A case of unsuccessful TRA-MT, due to nonbovine left common carotid artery origin associated with acute angulation of proximal brachiocephalic trunk (A). Rist guide catheter couldn’t navigate further due to a tendency of prolapsing into the aortic arch (B). An 8F femoral access was obtained with straightforward catheterization of common carotid artery (C). TRA, transradial approach; MT, mechanical thrombectomy.

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  Fig. 3. Another case of unsuccessful TRA-MT, due to a radial artery loop in antecubital region which was deemed to be harmful to cross (A). An 8F femoral access was obtained with straightforward catheterization of left common carotid artery (B). TRA, transradial approach; MT, mechanical thrombectomy.

Reference

1. Schartz D, Akkipeddi SMK, Ellens N, Rahmani R, Kohli GS, Bruckel J, et al. Complications of transradial versus transfemoral access for neuroendovascular procedures: a meta-analysis. J Neurointerv Surg. 2022; 14:820–825.

2. Satti SR, Sivapatham T, Eden T. Radial artery neuro guide catheter entrapment during mechanical thrombectomy for acute ischemic stroke: rescue brachial plexus block. Interv Neuroradiol. 2020; 26:681–685.

3. Siddiqui AH, Waqas M, Neumaier J, Zhang JF, Dossani RH, Cappuzzo JM, et al. Radial first or patient first: a case series and meta-analysis of transradial versus transfemoral access for acute ischemic stroke intervention. J Neurointerv Surg. 2021; 13:687–692.

4. Molinaro S, Russo R, Mistretta F, Risi G, Bergui M. Maximizing the available space: the new RED 062 aspiration catheter in conjunction with 7F guide catheter in mechanical thrombectomy for left anterior circulation stroke via direct transradial approach. Clin Neuroradiol. 2023; 33:865–868.

5. Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke. 2013; 44:2650–2663.

6. Jirous S, Bernat I, Slezak D, Miklik R, Rokyta R. Post-procedural radial artery occlusion and patency detection using duplex ultrasound vs. the reverse Barbeau test. Eur Heart J Suppl. 2020; 22(Suppl F):F23–F29.

7. von Kummer R, Broderick JP, Campbell BC, Demchuk A, Goyal M, Hill MD, et al. The Heidelberg Bleeding Classification: classification of bleeding events after ischemic stroke and reperfusion therapy. Stroke. 2015; 46:2981–2986.

8. Phillips TJ, Crockett MT, Selkirk GD, Kabra R, Chiu AHY, Singh T, et al. Transradial versus transfemoral access for anterior circulation mechanical thrombectomy: analysis of 375 consecutive cases. Stroke Vasc Neurol. 2021; 6:207–213.

9. Barranco-Pons R, Caamaño IR, Guillen AN, Chirife OS, Quesada H, Cardona P. Transradial versus transfemoral access for acute stroke endovascular thrombectomy: a 4-year experience in a high-volume center. Neuroradiology. 2022; 64:999–1009.

10. Sur S, Snelling B, Khandelwal P, Caplan JM, Peterson EC, Starke RM, et al. Transradial approach for mechanical thrombectomy in anterior circulation large-vessel occlusion. Neurosurg Focus. 2017; 42:E13.

11. 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; 11:874–878.

12. Munich SA, Saganty RS, Joshi KC, Radaideh Y. Evolution of transradial access for mechanical thrombectomy-a single center experience. Neurosurgery. 2023; 92:795–802.

13. Yoo BS, Yoon J, Ko JY, Kim JY, Lee SH, Hwang SO, et al. Anatomical consideration of the radial artery for transradial coronary procedures: arterial diameter, branching anomaly and vessel tortuosity. Int J Cardiol. 2005; 101:421–427.

14. Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, RIVAL Trial Group, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011; 377:1409–1420.