A Comparison of Outcomes Between Transfemoral Versus Transradial Access for Carotid Stenting

Anatomical and geometric considerations for transradial versus transfemoral approach to extracranial carotid artery stenting

Background and purposeThe transradial (TR) approach is an alternative to the traditional transfemoral (TF) approach for extracranial carotid artery stenting (eCAS). A successful eCAS may be contingent on the geometry of the great vessels. We aimed to analyze the vessel geometry to identify predictors for successful stent placement, enabling tailored approaches.Materials and methodsMulticenter retrospective data was collected from the electronic health record of patients who underwent eCAS from January 2018 to December 2022. Geometric parameters for great vessels were measured using computed tomography angiography (CTA) or magnetic resonance angiography (MRA). A successful approach was defined as completing eCAS without conversion. We performed a geometric analysis of features correlated with complications and successful completion of eCAS.Results1346 patients underwent TF (1081) and TR (265) eCAS. Conversion from TR to TF occurred in 44 cases (17%). Three TF cases required conversion. Complication rates did not differ between approaches (P = .773), but converting to TF had significantly higher Category 1 complications (P < .001). A smaller angle of origin of the left common carotid artery (A3) correlated with increased complications (P = .039), particularly with angles <90°, peaking at 50°. No other geometric features predicted the success.ConclusionBoth TR and TF stenting can be safely performed for carotid disease, but the angle of the left carotid artery origin predicted an increased risk of complications. No other aortic arch types or great vessel geometry predicted complications. Conversion from TR to TF predicted increased stroke, ICH, and MI.

Procedural Feasibility and Peri-procedural Outcomes of Peripheral Endovascular Therapy via Transradial versus Transfemoral Access: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the safety and feasibility of transradial access for peripheral vascular interventions.

DATA SOURCES

MEDLINE and Embase.

REVIEW METHODS

MEDLINE and Embase databases were searched to June 2023 to identify studies investigating the outcomes of lower extremity, carotid, and visceral artery vascular interventions via transradial vs. transfemoral access. The primary outcome was procedural failure rate. Secondary outcomes were total access site complications, minor and major bleeding, stroke, access vessel occlusion, procedure time, fluoroscopy time, and contrast volume.

RESULTS

Eight randomised controlled trials and 29 observational studies yielded a total of 70 882 patients treated via transradial (n = 2 616) vs. transfemoral access (n = 68 338). The overall failure rate was 2.3 ± 0.7%, and the transradial approach was associated with a statistically significantly higher procedural failure rate than the transfemoral approach (3.9 ± 0.7% vs. 1.0 ± 0.3%; odds ratio [OR] 3.07, 95% confidence interval [CI] 1.84 - 5.12; I2 = 32%; p < .001). Subgroup analysis showed the highest failure rate in lower extremity interventions with 12.4 ± 4.9% for transradial vs. 4.0 ± 1.2% for transfemoral access. Conversely, procedural complications were statistically significantly fewer with transradial access for total access site complications (OR 0.64, 95% CI 0.45 - 0.91; I2 = 36%; p = .010). Minor bleeding was statistically significantly less with the transradial approach (OR 0.52, 95% CI 0.31 - 0.86; I2 = 30%; p = .010), whereas major bleeding and stroke rates were similar. Transradial access had more access vessel occlusion than transfemoral access (1.9% ± 0.5% vs. < 0.1% ± 0.0%; p = .004), although most remained asymptomatic. Procedure time, fluoroscopy time, and contrast volume were all comparable. GRADE certainty was low to moderate in most outcomes.

CONCLUSION

The transradial approach was associated with a higher procedural failure rate. Total access site complications and minor bleeding were lower with the transradial approach, albeit with more frequent access vessel occlusion. Transradial access may be a feasible and safe approach; however, appropriate patient selection is imperative.

Transradial artery access for carotid artery stenting: A pooled analysis

INTRODUCTION

Carotid artery stenting (CAS) through transradial access (TRA) is emerging as an alternative to carotid endarterectomy. However, the current evidence base is limited, mainly comprising single-center studies.

OBJECTIVE

This systematic review and meta-analysis aim to assess the safety and effectiveness of TRA for CAS, providing evidence to support clinical decisions.

METHODS

We conducted searches on PUBMED, Cochrane Library, Embase, and Web of Science databases, including studies on TRA for CAS. Studies with fewer than 20 patients, non-primary outcomes, and non-full-text articles were excluded.

RESULTS

We analyzed 14 studies involving 1,166 patients who underwent CAS via TRA. Procedural success rate was high in 13 studies, with a 95% rate (95% CI; 92%-98%). Crossover to TFA access was observed in 12 studies at 6% (95% CI: 3%-9%). Transradial access failure was reported in four studies, with a rate of 0% (95% CI: 0%-0%). Cannulation failure resulted in a rate of 4% (95% CI: 2%-7%). Asymptomatic radial artery occlusion (ARAO) occurred at a rate of 2% based on eight studies (95% CI: 0%-5%). Forearm hematoma was reported in 10 studies, with an occurrence of 1% (95% CI: 0%-2%). Cerebral vascular attacks (CAV) within 30 days were assessed in 13 studies, indicating a 2% occurrence (95% CI: 1%-2%).

CONCLUSION

The findings suggest that TRA for CAS yields promising outcomes with high success rates and low complication rates. Further research should focus on randomized controlled trials and long-term outcomes to validate and extend findings.