Making Neuroendovascular Therapy for Cerebrovascular Disease Using Distal/Trans-radial Artery Access Safer.

Neuroendovascular therapy using distal/trans-radial artery access (d/TRA) has attracted attention as a less invasive procedure. We have selected dTRA or TRA in all cases of carotid artery stenting (CAS). In recent years, TRA has been actively selected for mechanical thrombectomy for acute ischaemic stroke (MT for AIS) and Onyx embolisation for arteriovenous malformations. We compared the patient background, surgical strategy, perioperative complications, and outcome in 41 patients who underwent CAS in the first period (Apr 2017-Feb 2019) and 12 patients in the second period (Apr 2020-Feb 2022) avoiding trans-femoral artery access (TFA) as possible. We compared the patient background, surgical strategy, perioperative complications, and outcome in 46 patients who underwent MT for AIS via TFA from Apr 2022 to Dec 2022 as the first period and five patients who underwent MT for AIS via TRA from Jan 2023 to Sep 2023 as the second period. Concerning CAS, the second period included significantly more symptomatic cases, with a higher rate of edaravone use to prevent hyperperfusion and a significantly smaller sheath diameter. In the second period, CAS was performed in severe conditions; nevertheless, there was no significant difference between the two groups in terms of either the ratio of cases detected by postoperative diffusion-weighted imaging positive or the ratio of cases with puncture site-related complications (PSCs). Concerning MT for AIS, there were no significant differences between the two groups with the patient backgrounds. The percentage of effective reperfusion, time from puncture to recanalisation, and outcome in the second period were all non-inferior to those in the first period when conventional MT for AIS was performed. Even though we introduced d/TRA in patients with cognitive decline and inability to remain at rest during the perioperative period, we completely avoided PSCs via d/TRA. In particular, cerebral hyperperfusion syndrome after CAS and ischaemia-reperfusion injury or re-occlusion after MT were rare but critical perioperative complications, and near-infrared spectroscopy (NIRS) may be used to monitor these problems. We introduced intensive evaluation by NIRS if we had time to spare.

Comparing Transbrachial and Transradial as Alternatives to Transfemoral Access for Large-Bore Neuro Stenting: Insights From a Propensity-Matched Study.

RATIONALE AND OBJECTIVES: This study aimed to evaluate the safety and effectiveness of transbrachial access (TBA) and transradial access (TRA) compared to transfemoral access (TFA) for large-bore neuro stenting (≥7 F). METHODS: From January 2019 to January 2024, 4752 patients received large-bore neuro stenting in our center. The primary outcomes were procedural metrics. Safety outcomes were significant access site complications, including substantial hematoma, pseudoaneurysm, artery occlusion, and complications requiring treatment (medicine, intervention, or surgery). After propensity score matching with a ratio of 1:1:2 (TBA: TRA: TFA), adjusting for age, gender, aortic arch type, and neuro stenting as covariates, outcomes were compared between groups. RESULTS: 46 TBA, 46 TRA and 92 TFA patients were enrolled. The mean age was 67.8 ± 11.2 years, comprising 127 (69.0%) carotid artery stenting and 57 (31.0%) vertebral artery stenting. The rates of technical success (TBA: 100%, TRA: 95.7%, TFA: 100%) and significant access site complications (TBA: 4.3%, TRA: 6.5%, TFA: 1.1%) were comparable between the groups (P > 0.05). Compared to TFA, the TRA cohort exhibited significant delays in angiosuite arrival to puncture time (14 vs. 8 min, P = 0.039), puncture to angiography completion time (19 vs. 11 min, P = 0.027), and procedural duration (42 vs. 29 min, P = 0.031). There were no substantial differences in procedural time metrics between TBA (10, 14, and 31 min, respectively) and TFA. CONCLUSION: TBA and TRA as the primary access for large-bore neuro stenting are safe and effective. Procedural delays in TRA may favor TBA as the first-line alternative access to TFA.

Endovascular Thrombectomy for Radial Artery Occlusion in Neuro-Interventional Procedures: A Report of Two Cases.

Transradial access has garnered increasing popularity and acceptance among the neuro-interventional community. As this technique becomes commonplace for both diagnostic and interventional procedures, an understanding of potential complications and management is tantamount. Here, we describe two cases of thrombosed radial arteries successfully recanalized with traditional thrombectomy techniques. Two patients presented with aneurysmal subarachnoid hemorrhage and were found to have ruptured anterior communicating artery aneurysms. Both patients were deemed appropriate candidates for endovascular treatment. During attempted access, both patients were found to have occluded right radial arteries due to previous arterial access, one from a prior intervention and one from an arterial line placed at another facility. Thrombectomies were subsequently performed, one via manual aspiration through the access sheath and the other with a commercially available aspiration system. Both radial arteries were successfully recanalized and the interventions were completed via transradial access. Endovascular thrombectomy for radial artery thrombosis is a feasible and simple technique that can be employed to facilitate transradial access for neuro-endovascular procedures when a thrombosed radial artery is encountered. This technique can be attempted in cases of radial artery thrombosis prior to conversion to transfemoral access.

Stent graft implantation from distal radial access-A novel way to treat femoral access site complication during transcatheter aortic valve replacement: A case report.

In this paper, a case of an 82-year-old man who was admitted to our department with sever symptomatic degenerative aortic valve stenosis is presented and discussed. After all screening procedures, a successful transfemoral transcatheter aortic valve replacement was performed, but the closure of the femoral access was unsuccessful due to suture-based device failure. We decided to perform a prolonged balloon dilatation and external compression at the bleeding site, but the bleeding did not stop; therefore, an iCover stent graft was implanted from distal radial artery access using slender technique. Following that, the bleeding was stopped, and the patient had an uneventful outcome.

Efficacy and safety of sheathless guiding catheter for distal radial approach.

OBJECTIVES: This study aimed to assess the efficacy and safety of a sheathless guiding system in patients who underwent percutaneous coronary intervention (PCI) with distal radial access (DRA). BACKGROUND: Hyperion™ Sheathless® guiding catheter (Asahi Intecc, Japan), one of the latest 6-Fr guiding systems for transradial PCI characterized by novel outer dilator, is considered to facilitate smooth insertion of the catheter to the artery and may contribute to further reduction of access site complications in DRA. METHODS: Between October 2018 and January 2023, 286 patients underwent PCI with a Hyperion™ Sheathless® guiding catheter with DRA at two Japanese hospitals. Procedural success, bleeding complications, and radial artery occlusion (RAO) detected by Doppler ultrasonography were assessed. RESULTS: Mean age of the patients was 72.7 years, and 236 patients (82.5 %) were male. The target lesions were located in the right coronary artery, left anterior descending artery, left circumflex artery, and left main trunk in 81, 44, 50 patients, and 18 patients respectively. Procedural success rate was 99.7 % with no patients requiring conversion to conventional radial access. Two patients presented with a forearm hematoma equivalent to an Early Discharge After Transradial Stenting of Coronary Arteries Study hematoma classification Grade II and 23 with Grade I. No patient presented minor or major bleeding according to the Thrombolysis in Myocardial Infarction bleeding classification. RAO at 30-day follow-up was observed in 6 out of 277 patients (2.2 %). CONCLUSIONS: 6-Fr sheathless guiding system for PCI via DRA is feasible and associated with a low incidence of access site complications.

Hepatic artery chemoembolization with distal transradial access for primary hepatocellular carcinoma: a novel interventional therapy for peripheral tumors.

OBJECTIVE: To investigate the feasibility and safety of hepatic artery chemoembolization via the distal transradial access (dTRA). METHODS: The clinical data of 130 patients with primary hepatocellular carcinoma treated in The First Hospital of Jilin University between August 1, 2020 and December 31, 2020, were retrospectively analyzed. Patients were confirmed to have primary hepatocellular carcinoma by preoperative imaging or pathology, with Child-Pugh Grade A or B and persistently palpable distal radial pulses. After a negative Allen test, patients underwent transcatheter arterial chemoembolization (TACE) via dTRA. The puncture success rate, the average number of needles, puncture time, distal radial occlusion and wrist hematoma were used to evaluate the treatment efficacy in the patients. RESULTS: All the punctures were performed using 21G steel needles. 5F sheaths were used for 84 cases, and 4F sheaths for 46 cases. The total was 130 cases. Among the 130 cases, 112 cases (86.2%) were successful in the puncture, 18 cases (13.8%) failed in the puncture. The success rate of the descending aorta selection using an MPA1 catheter (Cordis, Santa Clara, CA, USA) was 96.2% (125/130). In the remaining 5 cases, the selection succeeded after a 5F pigtail catheter was used instead. The success rate of the celiac trunk or superior mesenteric artery selection using an MPA1 catheter was 100%. No bleeding or hematoma occurred after 2-4 hours of compression following distal radial artery puncture, and both distal and proximal radial artery pulses were palpable. No arterial dissection or pseudoaneurysm was found, and there was no distal radial artery occlusion. Fourteen patients underwent 2 sessions of distal radial artery punctures, and no vascular occlusion was found in these patients either. CONCLUSIONS: TACE via the dTRA is feasible and safe for primary hepatocellular carcinoma.

Radial Arteriovenous Fistula After a Left Heart Catheterization: Two Case Reports.

The distal transradial artery (TRA) approach has been increasing in popularity over recent years due to its favorable ergonomics and potential for fewer vascular complications. Other advantages include lower bleeding risk, early ambulation, lower procedural costs, and same-day discharge, resulting in additional cost savings. We discuss two cases of patients who underwent left heart catheterizations through the radial artery access site and afterwards experienced fistula formation. Our case series brings to light a rare occurrence of arteriovenous fistulas (AVFs) following cardiac catheterization via the transradial artery site, thus enhancing our knowledge of the risk associated with this access site. The pathophysiology of AV fistula remains the same regardless of transfemoral or transradial artery use. During the procedure, needle diversion into the venous tributary results in an unrecognized combined artery and vein puncture, which usually seals spontaneously. However, if the communication persists, an AV fistula may occur. The majority of patients who suffer from an iatrogenic AVF as a result of TRA do not develop clinical signs of hemodynamic significance. There are various therapeutic strategies, which include surgical repair, placement of a covered stent, ultrasound-guided compression of the AV fistula, and conservative management. Both of our patients were evaluated by vascular surgery; one of the patients found the constant pulsation and bruit burdensome and underwent surgical repair.

Percutaneous Superficial Temporal Artery Access Facilitating Carotid Artery Stenting Performed From Distal Radial Artery.

PURPOSE: The purpose of the study is to describe carotid artery stenting (CAS) via distal transradial access (dTRA) facilitated by additional superficial temporal artery (STA) access, in a patient with complex aortic arch vessel anatomy. TECHNIQUE: A 72-year-old woman with a prior history of complex cervical surgery and radiotherapy due to laryngeal malignancy, presented with a symptomatic 90% stenosis of the left internal carotid artery (ICA). Due to high cervical lesion, the patient was rejected from carotid endarterectomy. Angiography demonstrated 90% stenosis of the left ICA and a type III aortic arch. After failure of left common carotid artery (CCA) cannulation with appropriate catheter support via dTRA and transfemoral approaches, CAS was attempted a second time. After percutaneous ultrasound guided access to right dTRA and left STA, a 0.035 inch guidewire introduced to the left CCA from the contralateral dTRA was snared and externalized via left STA to improve wire support for guiding advancement. Thereafter, the left ICA lesion was successfully stented with a 7×30 mm self-expanding stent via right dTRA. All vessels involved were patent at 6-month follow-up. CONCLUSION: The STA may be a promising adjunctive access site to increase transradial catheter support for CAS or neurointerventional procedures in the anterior circulation. CLINICAL IMPACT: Transradial cerebrovascular interventions have been gaining popularity, however, unstable catheter access to distal cerebrovascular structures limits its widespread use. Guidewire externalization technique via additional STA access may improve transradial catheter stabilty and increase procedural success with possibly low access stie complication rate.

Superficial temporal artery access for carotid artery stenting: A case report.

Percutaneous intervention of patients who suffer from generalized vascular disease is often a great challenge due to the limited accessibility of the access gates. We discuss the case of a 66-year-old man who presented with critical right internal carotid artery (ICA) stenosis after previous hospitalization due to stroke. In addition to arteria lusoria, the patient had known bilateral femoral amputation, occlusion of the left ICA and significant three-vessel coronary artery disease. After unsuccessful common carotid artery (CCA) cannulation from the right distal radial artery access, we successfully performed the diagnostic angiography and the planned right ICA-CCA intervention using superficial temporal artery (STA) puncture. We showed that STA access can be used as an alternative and additional access site for diagnostic carotid artery angiography and intervention when standard access sites alone are insufficient.

All that glitters: case presentation and review of radial access complications in neurointervention.

Radial artery access has experienced increasing adoption and rapid expansion of indications for neurointerventional procedures. This access is an attractive neurointervention route to be considered, with many advantages over the traditional femoral access in terms of ease of vasculature navigation and decreased risk of complications such as significant bleeding. Although a promising technique for neurointerventional procedures, there are inherent and unique considerations as well as potential complications involved. The following case report highlights some of these vital concepts associated with radial artery access, including appropriate patient selection as well as assessment of arterial size in the context of neurointerventional techniques. Early identification of complications such as arterial injury and compartment syndrome, with an emphasis on appropriate draping and inter-procedure monitoring, is discussed as well as approaches for subsequent management. Finally, the issue of radiation safety in this emerging technique is considered. These concepts are critical for the successful use and the continued growth of radial artery access for neurointervention procedures.

Radial arterial access is a safe alternative to brachial artery and femoral artery access for endovascular lower extremity peripheral arterial disease.

OBJECTIVE: Radial artery access is a well-described technique that has proven to be safe and efficacious in percutaneous cardiac intervention. This technique has been used with increased frequency in the treatment of lower extremity peripheral arterial disease (LE-PAD); however, the overall safety has not yet been well described in the vascular surgery literature. We sought to evaluate the safety of this technique compared with retrograde femoral artery access and brachial artery access (BA) in the treatment of PAD. METHODS: The Vascular Quality Initiative database was used to identify all patients who underwent single site percutaneous access (retrograde femoral access [FA], BA, radial access [RA]) for treatment of LE-PAD from September 2016 through September 2019. Patients who underwent multiple access sites for intervention were excluded. Primary outcome was significant access site complications (ASCs), defined as those requiring treatment (blood transfusion, interventional treatment, or surgical treatment). Minor ASCs were also reported. RESULTS: The cohort comprised 61,203 patients (270 RA, 1210 BA, and 59,723 FA) with an average age of 68 years and who were 59.6% male. The RA and BA groups had higher rates of prior endarterectomy or bypass compared with the FA group (66.7% RA; 86.0% BA; 50.2% FA; P < .001). RA was more often used for single-segment treatments (82% vs 74% [P < .020] and more aortoiliac arterial segments (59.6% vs 21.0% [P < .001]). ASC occurred in 1329 patients (2.7%), including minor ASC (996 [1.6%]) and significant ASC (333 [0.54%]). Significant ASC were less common after FA and RA compared with BA (RA, 1 [0.37%]; FA, 307 [0.51%]; BA, 25 [2.1%]; P < .001). On multivariate analysis, BA was the strongest predictor of significant ASC (odds ratio, 2.75; 95% confidence interval, 1.73-4.36; P < .001). Significant ASC was no different after RA compared with FA (odds ratio, 0.60; 95% confidence interval, 0.08-4.33; P = .616). Other factors independently associated with significant ASC were sex, age, diabetes, chronic obstructive pulmonary disease, dialysis, and closure device use. CONCLUSIONS: RA as the primary access vessel for endovascular treatment of LE-PAD is safe when compared with other traditional access sites. When FA is not possible or desirable, the radial approach may provide suitable access to treatment with a better safety profile than BA.

Ambulatory Same-Day Map-and-Treat Angiography for Selective Internal Radiation Therapy Using a Transradial Approach.

Historically, selective internal radiation therapy (SIRT) with yttrium-90 (Y-90) requires a two-week interval between workup and treatment (map and treat). The intervening gap between workup and treatment is used to plan for the dose required and obtain delivery of the radioactive Y-90. During the coronavirus disease 2019 pandemic, the delivery of a robust SIRT service was challenging due to unprecedented demands on all hospital services. Emergent practice changes were required to ensure this service could still be delivered to patients while retaining sufficient inpatient hospital beds and services for acutely unwell patients. In response to this, the interventional radiology team proposed the retention of a full SIRT service by removing the historical two-week interval between map and treat, delivering both components of the SIRT procedure on the same day. A traditional approach using femoral access would require a prolonged period of immobility and potentially an overnight stay. By adopting a transradial approach without sedo-analgesia, an ambulatory day-case map and treat SIRT with no post-procedure immobilisation was performed. This case report demonstrates the technical feasibility of same-day 'map-and-treat' SIRT, highlighting a paradigm shift from the conventional femoral access method and immobilisation to an 'ambulatory' approach with immediate mobilisation post-procedure.

Transradial Intracranial Aneurysm Coiling in a Seven-Year-Old Patient.

Pediatric intracranial aneurysms (PIA) are very rare and can be fatal if left untreated. There are many treatment strategies including microsurgical and endovascular techniques. We feel that endovascular treatment using trans-radial access (TRA) is safe and convenient for PIA compared to the trans-femoral access (TFA), which is commonly employed in this population. We present the case of the youngest patient in the world whose ruptured aneurysm was treated with endovascular coiling via the TRA. The seven-year-old patient was brought to the ER with a severe headache. He had several episodes of vomiting and an episode of seizure as well. Computerized tomography (CT) of the brain showed subarachnoid hemorrhage. A magnetic resonance angiogram (MRA) showed an aneurysm at the bifurcation of the right internal carotid artery (ICA). An intermediate catheter/microcatheter system was used to navigate up into the ICA and then into the aneurysm. Two coils were deployed with good packing. The patient had a good clinical recovery and is currently doing good without any neurological deficits. With the availability of newer devices, we believe the TRA will be widely used in the coming years. We need to have larger randomized controlled trials to really understand the advantages of TRA in this patient population.

Feasibility and Safety of Transradial Aneurysm Embolization: A Systematic Review and Meta-Analysis.

OBJECTIVE: Use of the transradial access (TRA) approach for neuroendovascular procedures has been increasing in recent years. Our aim is to assess the feasibility, success rate, and complications associated with TRA for intracranial aneurysm embolization. METHODS: PubMed, Scopus, and Embase were systematically searched for studies using TRA for intracranial aneurysm embolization. Random-effects models were used to obtain pooled rates of procedural success and complications. RESULTS: Twenty-four studies comprising 1283 (85.9%) TRA and 122 (8.2%) distal TRA aneurysm embolization procedures were included. The pooled success rate of the 18 studies in the meta-analysis was 93.5% (95% confidence interval [CI], 91.1%-95.8%). The pooled thromboembolic complication rate was 0.5% (95% CI, 0.1%-0.9%), the hemorrhagic complication rate was 0.5% (95% CI, 0.1%-0.9%), and the access site complication rate was 0.8% (95% CI, 0.3%-1.3%). One study (4.3%) used exclusively a 7-French guide catheter, and most used a 6-French guide catheter (22 of 23 studies, 95.7%), which was further incorporated as part of a triaxial configuration through a sheathless 8-French system in 4 studies (17.4%), 7-French guide catheter in 2 studies (8.7%), and 8-French sheath in 1 study (4.3%). The embolization techniques used were flow diverter placement in 451 cases (39.1%), coiling in 376 (32.6%), stent-assisted coiling in 127 (11.0%), balloon-assisted coiling in 104 (9.0%), Woven EndoBridge system in 50 (4.3%), and flow diverter placement plus coiling in 42 (3.6%). CONCLUSIONS: Treating intracranial aneurysms using various embolization techniques through TRA is feasible and associated with low access site and intraoperative complications.

Transradial versus Transfemoral Approaches in Diagnostic and Therapeutic Neuroendovascular Interventions: A Meta-Analysis of Current Literature.

BACKGROUND: The adoption of the transradial approach (TRA) has been increasing in popularity as a primary method to conduct both diagnostic and therapeutic interventions. As this technique gains broader acceptance and use within the neuroendovascular community, comparing its complication profile with a better-established alternative technique, the transfemoral approach (TFA), becomes more important. This study aimed to evaluate the safety of TRA compared with TFA in patients undergoing diagnostic, therapeutic, and combined neuroendovascular procedures. METHODS: A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of PubMed and other databases was conducted for studies from all available dates. To compare TRA and TFA, we performed an indirect meta-analysis between studies that mentioned the complications of the procedures. RESULTS: Our search yielded 532 studies, of which 108 met full inclusion criteria. A total of 54,083 patients (9137 undergoing TRA and 44,946 undergoing TFA) were included. Access site complication rate was lower in TRA (1.62%) compared with TFA (3.31%) (P < 0.01). Neurological complication rate was lower in TRA (1.64%) compared with TFA (3.82%) (P = 0.02 and P < 0.01, respectively). Vascular spasm rate was higher in TRA (3.65%) compared with TFA (0.88%) (P < 0.01). Wound infection complication rate was higher in TRA (0.32%) compared with TFA (0.2%) (P < 0.01). CONCLUSIONS: Patients undergoing TFA are significantly more likely to experience access site complications and neurological complications compared with patients undergoing TRA. Patients undergoing TRA are more likely to experience complications such as wound infections and vascular spasm.

Transradial Retrograde Percutaneous Coronary Intervention of Chronic Total Occlusion via an Ipsilateral Septal Collateral Using a Single Guiding Catheter: A Case Report.

BACKGROUND: With the development of specialized equipment and the retrograde technique, success rates for percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) have increased from 60 to 90% in the past 10 years. Performing PCI via a collateral channel from the contralateral artery, using two guiding catheters, is usually the preferred approach to retrograde CTO-PCI. In the case described in this report, only the ipsilateral septal collateral artery from the proximal occluded left anterior descending (LAD) artery was available. The procedure can be performed successfully from radial artery access using a single guiding catheter. CASE SUMMARY: A 57-year-old patient, with a history of anterior and inferior myocardial infarction and previous PCI, underwent a planned coronary arteriography due to his complaints of typical angina symptoms. Coronary angiography revealed stent occlusion located mid-LAD and severe in-stent restenosis in the distal right coronary artery (RCA). A proximal septal branch was supplying the distal LAD retrogradely. After repeated failed attempts at antegrade PCI for the LAD's CTO, the retrograde approach was tried. This intervention finally succeeded through the ipsilateral septal collateral. It was performed via a single radial-artery access throughout the whole process. Post-operatively, the patient had no complications and was stable at 1-year follow-up. CONCLUSION: The transradial approach to retrograde PCI for CTO via an ipsilateral septal collateral using a single guiding catheter is feasible and safe in appropriately selected cases.

Common ground, different path: Ulnar artery access for interventional neurovascular procedures.

BACKGROUND: Recently, radial artery access has gained popularity for interventional neurovascular procedures due to patient comfort and fewer complications. However, there are instances where the radial artery approach is not feasible. In such cases, trans-ulnar artery access (TUA) can offer an alternate route. There is limited data regarding neuro-interventional procedures performed via this approach. This study aims to evaluate the feasibility and safety of trans-ulnar approach for a wide range of interventional neurovascular procedures. MATERIALS AND METHODS: The data for all patients who underwent ulnar artery access for diagnostic or interventional neuroradiology procedures was retrospectively collected between September 2020 and March 2021. Patient demographics, procedural details, procedure success, and complications were recorded. RESULTS: During the study period, 23 patients underwent 24 trans-ulnar approach procedures. The mean age of patients was 50.1 ± 14.2 years. Fourteen diagnostic cerebral angiograms and ten interventional procedures were performed. All procedures were successfully completed via trans-ulnar approach without a switch to alternate access. No major access site complication was observed. CONCLUSION: Ulnar artery access is a safe and feasible option for neurovascular procedures. It can be effectively utilized for diagnostic cerebral angiography and a wide range of interventional procedures.