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

Percutaneous Closure Device for the Carotid artery: An integrated review and design analysis

Endovascular thrombectomies (EVTs) are the current standard of care therapy for treating acute ischemic strokes. While access through the femoral or radial arteries is routine, up to 20% of EVTs through these sites are unable to access the cerebral vasculature on the first pass. These shortcomings are commonly due to tortuous vasculature, atherosclerotic arteries, and type III aortic arch, seen especially in the elderly population. Recent studies have shown the benefits of accessing the cerebral vasculature through a percutaneous direct carotid puncture (DCP), which can reduce the time of the procedure by half. However, current vascular closure devices (VCDs) designed for the femoral artery are not suited to close the carotid artery due to the anatomical differences. This unmet clinical need further limits a DCP approach. Thus, to foster safe adoption of this potential approach, a VCD designed specifically for the carotid artery is needed. In this review, we outline the major biomechanical properties and shortcomings of current VCDs and propose the requirements necessary to effectively design and develop a carotid closure device.

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

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.

Crossover from Femoral to Radial Access During Mechanical Thrombectomy of Large Vessel Occlusion Stroke

BACKGROUND

Challenging arterial anatomy may prevent timely endovascular treatment (EVT) of acute ischemic stroke (AIS) through a transfemoral approach prompting the use of alternative access routes. We determined the crossover rate from femoral to radial access during EVT of AIS due to large vessel occlusion and identified its radiological predictors and clinical outcomes.

MATERIALS AND METHODS

Retrospective review of all AIS patients who underwent EVT at a single institution from January 2016 to March 2021 was performed. A primary and a secondary radial group depending on whether the radial approach was used primarily or secondary to failure of transfemoral approach were compared.

RESULTS

A total of 358 consecutive AIS patients with large vessel occlusion underwent EVT. Radial approach was used primarily in 6 patients (primary radial [PR]) and secondarily in 16 patients (secondary radial [SR]). The rate of femoral to radial crossover was 4.7%. Type III arch and bovine arch configurations were the most common characteristic in the crossover group. Radial access was successful to secure intracranial access in all cases of PR and in 87% of crossover cases. There was no significant difference between the rates of successful reperfusion (53.3% SR, 83% PR, P = 0.20), National Institutes of Health Stroke Scale score on discharge (19 SR, 18 PR group, P = 0.90), or good outcome defined as modified Rankin Scale score 0-2 (13.3% SR, 33.3% PR, P = 0.29).

CONCLUSIONS

A radial approach can be considered during EVT of AIS due to large vessel occlusion either primarily or secondarily with a lower threshold to switch from the femoral approach in cases of challenging anatomy.

Endovascular treatment vs drug therapy alone in patients with mild ischemic stroke and large infarct cores

BACKGROUND

Treatment decision making is strictly associated with the outcomes in patients with ischemic stroke who show a large core infarct. Medical care alone may result in suboptimal treatment efficacy, and endovascular treatment may be accompanied by safety issues. Whether endovascular treatment is superior to medical care is not well investigated in the clinical studies.

AIM

To investigate the efficacy of endovascular treatment and drug therapy alone in mild ischemic stroke patients with large infarct cores.

METHODS

Fifty patients with mild ischemic stroke and 50 patients with acute ischemic stroke caused by anterior large vessel occlusion were selected at the First Affiliated Hospital of Hebei North University between January 2021 and December 2021. Patients were divided into an endovascular therapy group and a drug therapy group according to different treatment methods. In the endovascular therapy group, there were 28 patients with minor stroke and 22 patients with large infarct cores. The drug therapy group had 22 patients with minor stroke and 28 patients with large infarct cores. The National Institutes of Health Stroke Scale (NIHSS) scores were collected and compared between the two groups immediately after the operation and 24 h and 7 d after the operation. The modified Rankin scale (mRS) and/or activity of daily living were assessed at hospital discharge.

RESULTS

There was no significant difference in NIHSS scores between the two groups before the operation (P > 0.05). NIHSS scores were lower in the endovascular therapy group than in the drug therapy group at 24 h and 7 d after the operation and at hospital discharge (all P < 0.05). The incidence of early neurologic deterioration was significantly lower in the endovascular therapy group than in the drug therapy group (P < 0.05). At hospital discharge, the mRS score was lower in the endovascular treatment group than in the drug therapy group, and the activity of daily living score was better in the endovascular treatment group than in the drug therapy group (all P < 0.05). During a follow-up of 3 mo, 17 patients (34.0%) had good prognosis (mRS ≤ 2), 33 patients (66.0%) had poor prognosis (mRS > 2), and 11 patients (22.0%) died. In the medical treatment group, 16 patients (mRS ≤ 2) had good prognosis (32.0%), 34 patients (mRS > 2) had poor prognosis (68.0%), and 14 patients (28.0%) died. There was no significant difference in prognosis and mortality between the two groups (P > 0.05).

CONCLUSION

Endovascular therapy can improve NIHSS score and mRS score in patients with mild ischemic stroke and large infarct cores. It is suitable for clinical application.

Direct carotid artery puncture for acute ischemic stroke: Local experience and systematic review

BACKGROUND

To establish surgical access during endovascular treatment of ischemic stroke, femoral artery puncture is most commonly performed followed by a small number of radial artery access procedures. However, there are few reports of carotid artery puncture.

METHODS

We report the case of an 87-year-old woman who was admitted to hospital with hemiplegia of the left limb and loss of consciousness for 40 min, accompanied by urinary incontinence. After complicated transfemoral and transradial attempts, the patient underwent emergency direct carotid artery puncture (DCAP) for the treatment of acute ischemic stroke. We reviewed the literature on this topic over a 7-year period (September 2014 to April 2022), including 202 patients with acute ischemic stroke who underwent emergency DCAP and endovascular surgery.

RESULTS

The average age of these patients was 80.5 years. The left DCAP accounted for 52.5% (106/202) of the cases. Local anesthesia was utilized in 33.9% (64/189) of the cases. Angio-Seal was utilized for closure in 53.7% (79/147) of the patients. About half (105/199) of the patients recovered or improved their limb function after DCAP. Postoperative complications were mainly neck hematoma and one of these patients died due to a fatal neck hematoma.

CONCLUSION

We describe the detailed procedure of the rare case of an emergency DCAP performed at our institution. DCAP provides an alternative treatment method in cases where thrombus removal access cannot be established through traditional methods.

Direct Carotid Puncture for Mechanical Thrombectomy in Acute Ischemic Stroke: Literature Review and a Single-Center Experience

BACKGROUND

Endovascular thrombectomy (EVT) for acute ischemic stroke via direct carotid puncture (DCP) has been commonly reported as case reports and series in the literature. However, the reported procedural risk and therapeutic outcome associated with this approach were variable. In this study, we aim to establish the role and safety profile of this alternative access technique by describing our single-center experience and conducting a comprehensive review of the literature.

METHODS

We conducted a retrospective review of consecutive patients at our center with large vessel occlusion (LVO) treated between 2018 and 2020 with DCP access. In addition, a literature review of studies published from 2012-2021 following PRISMA guidelines was conducted.

RESULTS

During the 3-year period, 11 patients with LVO were treated with EVT using DCP technique in our local cohort. A total of 216 cases were found in the literature search. A combined total of 227 cases were reviewed separately and collectively. Combining the data, DCP access was successfully achieved in 93.3% of the cases; 76.6% achieved satisfactory recanalization (mTICI ≥2b). DCP-related complications were seen in 20.3% of cases. A total of 32.4% patients were functionally independent (mRS ≤2) upon follow-up.

CONCLUSIONS

Results from the literature review and our experience illustrate DCP as a feasible approach for EVT. The role of DCP as a bailout is iterated despite a higher complication risk, which may be imperative in low-volume stroke centers. Further studies to evaluate the role of DCP as a primary vascular access technique for EVT in selected cases could be explored.

Patient and procedure selection for mechanical thrombectomy: Toward personalized medicine and the role of artificial intelligence

Mechanical thrombectomy (MT) for ischemic stroke due to large vessel occlusion is standard of care. Evidence-based guidelines on eligibility for MT have been outlined and evidence to extend the treatment benefit to more patients, particularly those at the extreme ends of a stroke clinical severity spectrum, is currently awaited. As patient selection continues to be explored, there is growing focus on procedure selection including the tools and techniques of thrombectomy and associated outcomes. Artificial intelligence (AI) has been instrumental in the area of patient selection for MT with a role in diagnosis and delivery of acute stroke care. Machine learning algorithms have been developed to detect cerebral ischemia and early infarct core, presence of large vessel occlusion, and perfusion deficit in acute ischemic stroke. Several available deep learning AI applications provide ready visualization and interpretation of cervical and cerebral arteries. Further enhancement of AI techniques to potentially include automated vessel probe tools in suspected large vessel occlusions is proposed. Value of AI may be extended to assist in procedure selection including both the tools and technique of thrombectomy. Delivering personalized medicine is the wave of the future and tailoring the MT treatment to a stroke patient is in line with this trend.

Direct carotid puncture for endovascular surgery of intracranial aneurysms: Technical note for avoiding complications

Background:

While the most intracranial aneurysms are approachable by femoral or brachial artery puncture during endovascular surgery, in some cases, the lesion is difficult to reach due to complications such as the presence of winding pathways. Direct carotid puncture (DCP) is an alternative access approach, despite the potential risk of fatal neck hematoma. Herein, we describe the DCP technique in a series of five patients with intracranial aneurysms, together with its technical considerations.

Methods:

Patients with intracranial aneurysms who underwent endovascular surgery using DCP were reviewed retrospectively. We selected the 3F to 6F systems for DCP depending on the necessity of adjunctive techniques. To prevent DCP-associated complications, we (1) conducted a micropuncture before introducing the short sheaths,

(2) selected the smallest possible size for the system, (3) reversed heparin postoperatively, and (4) performed perioperative intubation/sedation management.

Results:

Five out of 535 patients underwent DCP in our hospital between 2015 and 2019; successful vascular access was achieved in all cases. Although a minor neck hematoma occurred in one case, the patient did not require additional treatment. According to a literature review, severe neck hematoma requiring rescue therapy occurs in 5 out of 95 cases (5.3%).

Conclusion:

Although the potential risk of neck hematoma is not negligible, the DCP technique appears to be a safe and effective approach in treating intracranial aneurysms with challenging access routes in cases where perioperative counter measurements are appropriately performed.

Roadmap Guided Direct Percutaneous Vertebral Artery Puncture for Mechanical Thrombectomy of Acute Basilar Artery Occlusion: A Technical Case Report and Review of the Literature

Access techniques for mechanical thrombectomy normally include percutaneous puncture of the common femoral or, more recently, the radial artery. Although target vessel catheterization may frequently not be devoid of difficulties via both routes, the vast majority of mechanical thrombectomy (MT) cases can be successfully managed. However, in a significant minority of cases, a stable target vessel access cannot be reached resulting in futile recanalization procedures and detrimental outcomes for the patients. As such, in analogy to direct carotid puncture for anterior circulation MT, direct vertebral artery (VA) puncture (DVP) is a direct cervical approach, which can constitute the only feasible access to the posterior circulation in highly selected cases. So far, due to the rarity of DVP, only anecdotal evidence from isolated case reports is available and this approach raises concerns with regard to safety issues, feasibility, and technical realization. We present a case in which bail-out access to the posterior circulation was successfully obtained through a roadmap-guided lateral direct puncture of the V2 segment of the cervical VA and give an overview of technical nuances of published DVP approaches for posterior circulation MT.

Systematic Review on Endovascular Access to Intracranial Arteries for Mechanical Thrombectomy in Acute Ischemic Stroke

PURPOSE

In acute ischemic stroke for large vessel occlusions, delayed or failed access to intracranial occlusions has a negative impact on procedural and clinical outcomes. The aim of this review is to identify and quantify access failures and challenges in mechanical thrombectomy.

METHODS

A systematic literature review of PubMed and Scopus databases from January 2014 to October 2020 was performed. Articles reporting consecutive patients were used to calculate a crude failure rate of femoral and alternative accesses.

RESULTS

A total of 50 articles met the inclusion criteria, totalling 12,838 interventions. Failure to access the occlusion through transfemoral access occurred in 4.4% of patients, most commonly due to challenging supra-aortic vessel anatomy, decreasing to 3.6% when all alternative access routes were attempted. Failed access from alternative routes (direct carotid, radial and brachial approaches) attempted first-line or after failed femoral attempt were reported in 7.3% of patients. The occurrence rate of potentially challenging features (anatomical, diseases or others) ranged from 4.7% to 47.4%, primarily impacting the access time, procedure time, recanalization and clinical outcomes.

CONCLUSION

Failure to access the occlusion is a significant contributor to failed recanalization, regardless of access routes. Challenging, but eventually successful access is also a relevant factor in procedural and clinical outcomes; however challenging access requires a universal definition to enable quantification, so that methods for procedural optimization can be critically assessed.

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.

Access-site complications in ultrasound-guided endovascular thrombectomy: a single-institution retrospective cohort study

OBJECTIVE

Mechanical endovascular thrombectomy (EVT) is an increasingly relied-on treatment for clot retrieval in the context of ischemic strokes, which otherwise are associated with significant morbidity and mortality. Despite several known risks associated with this procedure, there is a high degree of technical heterogeneity across both centers and operators. The most common procedural complications occur at the point of transfemoral access (the common femoral artery), and include access-site hematomas, dissections, and pseudoaneurysms. Other interventional fields have previously popularized the use of ultrasound to enhance the anatomical localization of structures relevant to vascular access and thereby reducing access-site complications. In this study, the authors aimed to describe the ultrasound-guided EVT technique performed at a large, quaternary neurovascular referral center, and to characterize the effects of ultrasound guidance on access-site complications.

METHODS

A retrospective chart review of all patients treated with EVT at a single center between January 2013 and August 2020 was performed. Patients in this cohort were treated using a universal, unique, ultrasound-guided, single-wall puncture technique, which bears several theoretical advantages over the standard technique of arterial puncture via palpation.

RESULTS

There were 479 patients treated with EVT within the study period. Twenty patients in the cohort were identified as having experienced some form of access-site complication. Eight (1.67%) of these patients experienced minor access-site complications, all of which were groin hematomas and none of which were clinically significant, as defined by requiring surgical or interventional management or transfusion. The remaining 12 patients experienced arterial dissection (n = 5), arterial pseudoaneurysm (n = 4), retroperitoneal hematoma (n = 2), or arterial occlusion (n = 1), with only 1.04% (5/479) requiring surgical or interventional management or transfusion.

CONCLUSIONS

The authors found an overall reduction in total access-site complications as well as minor access-site complications in the study cohort compared with previously published randomized controlled trials and observational studies in the recent literature. The findings suggested that there may be a role for routine use of ultrasound-guided puncture techniques in EVT to decrease rates of complications.

Exploring the path less traveled: Distal radial access for diagnostic and interventional neuroradiology procedures

BACKGROUND

Recently there is a trend for radial first which advocates radial artery access as the first choice to perform diagnostic and interventional neurovascular procedures. Although safer than the conventional common femoral artery access, it is associated with a high rate of radial artery occlusion. Distal radial artery access is recently proposed to avoid this complication. This study aims to assess the feasibility and safety of distal radial artery access across a wide range of interventional neurovascular procedures.

MATERIALS AND METHODS

All Interventional neurovascular cases attempted via distal radial artery access from September 2019 till March 2021 were included in the study. Data regarding patient demographics, distal radial artery diameter, access site cannulation, size of the sheath, procedural details including success rate and complications were collected.

RESULTS

During the study period, 102 patients underwent 114 procedures via the distal radial artery approach. The mean age of patients was 41.9 ± 15.2 years. Overall procedure success rate via DRA was 94.7% (108/114). 72 diagnostic cerebral angiograms and 36 interventional procedures were successfully completed while six procedures required switching to alternate access.

CONCLUSION

Distal radial artery access is a safe and feasible option for diagnostic cerebral angiography and a wide range of neurovascular procedures.

Vascular tortuosity in endovascular mechanical thrombectomy

Endovascular mechanical thrombectomy effectively removes occlusive thrombi from the arterial lumen; however, there is little literature supporting the relevance of vascular geometry on surgical outcomes. Critical vessel characteristics including the degree of angulation and tortuosity influence the ability to advance stent retriever devices toward the site of occlusion. Therefore, it is crucial to evaluate the impact of carotid artery catheter pathway accessibility on the thrombectomy outcomes in acute ischemic stroke (AIS) patients. Traditional imaging modalities generate incomplete pictures of the vascular tortuosity and are prone to clinical judgment errors. Recent three-dimensional computed tomography angiography image analysis techniques circumvent these limitations to calculate accurate tortuosity and angulation measurements. These novel images facilitate classifying common anatomical variant patients into groups that may be treated with specially designed catheter devices. Importantly, this image analysis method reveals significant angulation in the common carotid artery and extracranial internal carotid artery that correlates with delays in reaching the occlusion site. Increased age, which is associated with increased risk of stroke, also increases the incidence of severe tortuosity. The semi-automated measurements technique also demonstrate that full 360° arterial loops are present in nearly 3% of catheter pathways and that the overall degree of angulation differs bilaterally. In this review, we examine the utility of this novel image analysis procedure and evaluate the recent literature relevant to neuroendovascular thrombectomy in AIS patients. Three literature databases – PubMed, Embase, and Web of Science were queried for original articles investigating both preclinical and clinical thrombectomy applications.