Early exploration of the economic impact of transradial access (TRA) versus transfemoral access (TFA) for neurovascular procedures in Spain.

INTRODUCTION: Transfemoral access (TFA) is the primary access approach for neurointerventional procedures. Transradial access (TRA) is established in cardiology due to its lower complications, yet, it is at its early stages in neuroprocedures. This study performs an early exploration of the economic impact associated with the introduction of TRA in diagnostic and therapeutic neuroprocedures from the Spanish NHS perspective. METHODS: An economic model was developed to estimate the cost and clinical implications of using TRA compared to TFA. Costs considered access-related, complications and recovery time costs obtained from local databases and experts' inputs. Clinical inputs were sourced from the literature. A panel of eight experts from different Spanish hospitals, validated or adjusted the values based on local experience. Hypothetical cohorts of 10,000 and 1000 patients were considered for diagnostic and therapeutic neuroprocedures respectively. Deterministic sensitivity analysis was performed. RESULTS: TRA in diagnostic procedures was associated with lower costs with savings ranging between €486 and €157 depending on the TFA recovery time considered. TRA is estimated to lead to 158 fewer access-site complications. In therapeutic procedures, TRA resulted in 76.4 fewer complications and was estimated to be cost-neutral with an incremental cost of €21.56 per patient despite recovery times were not included for this group. Variation of the parameters in the sensitivity analysis did not change the direction of the results. LIMITATIONS: Clinical data was obtained from literature validated by experts therefore results generalizability is limited. In therapeutic neuroprocedures, there is an experience imbalance between approaches and recovery times were not included hence the total impact is not fully captured. CONCLUSIONS: The early economic model suggests that implementing TRA is associated with reduced costs and complications in diagnostic procedures. In therapeutic procedures, TRA lead to fewer complications and it is estimated to be cost-neutral, however its full potential still needs to be quantified.

Distal Transradial Artery Access for Neuroangiography and Neurointerventions : Pitfalls and Exploring the Boundaries.

INTRODUCTION: The distal transradial approach (dTRA) is progressively gaining more clinical use in the fields of cardiology and other vascular interventions, as it offers a number of advantages compared to conventional radial approach (TRA). These include lower rates of vascular occlusion which permits preservation of the proximal radial artery for future procedures in the event of a distal occlusion. AIM: To share the experience in the use of dTRA for neurointerventions, showing its advantages, pitfalls as well as sharing our optimized puncture and hemostatic ultrarapid compression protocols to improve the use of this vascular access. METHODS: A retrospective analysis of our experience of diagnostic and interventional procedures performed via dTRA using an optimized protocol for puncture and postpuncture compression of the dTRA was performed. The rate of complications (hematoma and arterial dissection at puncture site) femoral crossover, and assessment of postprocedural stenosis/occlusion with the ultrarapid compression protocol were also assessed. RESULTS: From March 2019 to July 2020 a total of 100 distal radial procedures were carried out and 53 diagnostic angiograms (53%) and 47 interventional procedures (47%) were included in the analysis. We achieved a 96% technical success, with a femoral crossover requirement in 3 cases (3%), and one conventional TRA crossover due to puncture failure. Of the patients 3 presented puncture site hematomas (3%) with no intervention required, 61 patients (61%) underwent the ultrarapid hemostasis protocol in association with a hemostatic pad. Ultrasound follow-up was performed in 20 patients (20%) at 1-2 months with 1 case of occlusion (5%) and 2 of radial stenosis (10%). In all 3 cases proximal radial artery remained patent. CONCLUSION: The dTRA is a safe and feasible access route for angiography and neurointerventions. Using vasodilators prepuncture, we attained a variable increase in the vascular diameter facilitating puncture and reducing the risk of occlusion and vascular spasm. A rapid deflation protocol for postpuncture hemostasis does not significantly increase the hematoma rate.

Transradial versus transfemoral access for acute stroke endovascular thrombectomy: a 4-year experience in a high-volume center.

PURPOSE: To compare clinical outcomes and safety of transradial (TRA) versus transfemoral access (TFA) for endovascular mechanical thrombectomy in acute stroke patients. METHODS: Retrospective analysis of 832 consecutive patients with acute stroke undergoing interventional thrombectomy using TRA (n = 64) or TFA (n = 768). RESULTS: Direct TFA failures occurred in 36 patients, 18 of which underwent crossover TFA to TRA, while direct TRA failures occurred in 2 patients having both crossovers to TFA. Successful catheterization was achieved in 96.8% (62/64) and 95.3% (732/768) of patients undergoing direct TRA and direct TFA, respectively, without significant differences. The median (IQR) catheterization time was 10 (8-16) min in the direct TRA group and 15 (10-20) in the direct TFA group (P < 0.001). This difference was also significant in the subgroup of anterior circulation strokes and in patients younger and older than 80 years of age. The majority of procedures yielded thrombolysis in cerebral infarction grade 2b/2c/3 revascularization in patients undergoing direct TRA (88.5%) and direct TFA (90.8%), without statistically significant differences. The median (IQR) puncture to recanalization time was 37 (24-58) min for the direct TRA group and 42 (28-70) min for the direct TFA group. Significant differences in access site complications, symptomatic ICH, and mRS score 0-2 at 90 days between both TRA and TFA accesses were not found. CONCLUSIONS: TRA is not inferior to TFA in the probability of catheterization, times of catheterization and revascularization, and other clinical outcomes for mechanical thrombectomy in acute stroke.

Early experience with a novel net temporary bridging device (Cascade) to assist endovascular coil embolization of intracranial aneurysms.

OBJECTIVE: The goal of this study was to evaluate the effectiveness and safety of a new noncompletely occlusive net-assisted remodeling technique in which the Cascade net device is used for temporary bridging of intracranial aneurysms. METHODS: Between July 2018 and May 2019, patients underwent coil embolization with the Cascade net device within 4 centers in Europe. Analysis of angiographic (modified Raymond-Roy classification [MRRC]) and clinical outcomes data was conducted immediately following treatment and at the 6-month follow-up. RESULTS: Fifteen patients were included in the study (mean age 58 ± 13 years, 11/15 [73.3%] female). Ten patients had unruptured aneurysms, and 5 presented with ruptured aneurysms with acute subarachnoid hemorrhage. The mean aneurysm dome length was 6.27 ± 2.33 mm and the mean neck width was 3.64 ± 1.19 mm. Immediately postprocedure, MRRC type I (complete obliteration) was achieved in 11 patients (73.3%), whereas a type II (residual neck) was achieved in 4 patients (26.7%). Follow-up examination was performed in 7/15 patients and showed stabilization of aneurysm closure with no thromboembolic complications and only 1 patient with an increased MRRC score (from I to II) due to coil compression. CONCLUSIONS: Initial experience shows that the use of a new noncompletely occlusive net-assisted remodeling technique with the Cascade net device may be safe and effective for endovascular coil embolization of intracranial aneurysms.

Transradial Comaneci-assisted coiling of a direct carotid-cavernous fistula.

Direct carotid-cavernous fistula is a communication between the internal carotid artery and the cavernous sinus, most of the times established following trauma or rupture of a cavernous aneurysm. The most commonly used treatments (coils, detachable latex balloons, stents, or liquid agents) carry ischemic or hemorrhagic risks, related to hemodynamic diversion of cerebral blood flow or permanent dual antiplatelet therapy. We report a case of coiling of a carotid-cavernous fistula assisted by the Comaneci, a temporary adjustable bridging mesh (Rapid Medical, Israel), to avoid transarterial or -venous migration. In our experience, Comaneci-assisted coiling represents a feasible solution to maintain patency of the distal vessels during coiling and avoid dual antiplatelet medications, even using a transradial approach.

Gross hemoglobinuria and oliguria are common transient complications of sclerotherapy for venous malformations: review of 475 procedures.

OBJECTIVE: The purpose of this article is to study the incidence, risk factors, and treatment of gross hemoglobinuria and oliguria following sclerotherapy for venous malformations. MATERIALS AND METHODS: The clinical records and imaging studies of 131 patients with venous malformations (57 male and 74 female patients; age range, 2-58 years) who underwent sclerotherapy at our institution between July 1993 and August 2007 were reviewed. Demographic data, the location and estimated size of the malformation, the type and dose of the sclerosing agents, development of postprocedural hemoglobinuria and oliguria, and the treatment given were documented and analyzed. RESULTS: Four hundred seventy-five sclerotherapy procedures were performed on 131 patients, with the number of procedures per patient ranging from 1 to 21 (mean, 3.6 procedures). Sodium tetradecyl sulfate was used in 47% of the procedures, ethanol in 27%, and both agents in 26%. Transient hemoglobinuria occurred after 34% of the sclerotherapy procedures, and 57% of these were associated with transient oliguria, with increased risk with higher adjusted doses (sclerosant volume/weight of patient) for both agents. Resolution of the hemoglobinuria and oliguria with hydration, alkalinization, and diuretics occurred in all patients. The risk of hemoglobinuria increased with higher adjusted dose (sclerosant volume/weight of patient) for both agents and with sclerotherapy of venous malformations affecting the lower extremities and multiple locations. CONCLUSION: Transient hemoglobinuria and oliguria are common complications of sclerotherapy for venous malformation. Nevertheless, with proper fluid management, all the patients promptly recovered. The risk correlates with the volume of sclerosant (adjusted to patient's weight) and is higher for lower extremity and multiple locations.