Lessons Learned After 760 Neurointerventions via the Upper Extremity Vasculature: Pearls and Pitfalls

Abstract

BACKGROUND The radial approach has been gaining more widespread use by neurointerventionalists fueled by data from the cardiology literature showing better safety and overall reduced morbidity. OBJECTIVE To present our institution's experience with the radial approach for neuroendovascular interventions in 614 consecutive patients who underwent a cumulative of 760 procedures. METHODS A retrospective analysis was performed and identified neuroendovascular procedures performed via the upper extremity vasculature access site. RESULTS Amongst 760 procedures, 34.2% (260) were therapeutic, and 65.7% (500) were nontherapeutic angiograms. Access sites were 71.5% (544) via a conventional radial artery, 27.8% (211) via a distal radial artery, 0.5% (4) via an ulnar artery, and 0.1% (1) via the brachial artery. Most of the procedures (96.9%) were performed via the right-sided (737), 2.9% (22) via the left-sided, and 0.1% (1) via a bilateral approach. Major access site complications occurred at a rate of 0.9% (7). The rate of transfemoral conversion was 4.7% (36). There was a statistically higher incidence of transfemoral conversion when repeat procedures were performed using the same access site. Also, there was no significant difference between nontherapeutic procedures performed using the right and left radial access, and conventional versus distal radial access. Procedural metrics improved after completion of 14 procedures, indicating a learning curve that should be surpassed by operators to reach optimal outcomes. CONCLUSION Radial artery catheterization is a safe and effective means of carrying out a wide range of neuroendovascular procedures associated with excellent clinical outcomes and an overall low rate of periprocedural complications.

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

“…Recently Ahmad et.al published their institutional experience of 760 neuro-interventions performed via upper extremity access. 23 They utilized ulnar artery access in only 0.5% (4/760) procedures. The scarce use of TUA for neuro-interventional procedures can be attributed to a steep learning curve.…”

Access Site Complications and Management of the Transradial Approach for Neurointerventions

“…The needle was then removed before advancement of a hydrophilic sheath over the wire and into the vessel. 18 A radial cocktail (2000 units of heparin, 5 mg of cardene, and 200 µg of nitroglycerin) is diluted in 20 cc of saline and injected through the sheath over 1 minute. The sheath is flushed clear with heparinized saline and then hooked up to continuous heparinized saline flush.…”

“…The hand, including thumb, is taped, so it is flexed to the board. 18 We typically use a Prelude (Merit Medical) radial sheath. A 5 Fr is usually used for diagnostic purposes and 6 Fr for interventions.…”

“…A sheathless system may be used where the guiding sheath provides additional proximal support for neurointerventions requiring larger devices. 18 Ultrasound is used to measure the RA and determine what size system it can accommodate. Larger bore catheters may be used for RA diameters ≥2.3 mm.…”

“…7,22,32 In type III arches, selecting the descending aorta can be challenging because of an inferiorly located brachiocephalic artery. 18,32 In the presence of arteria lusoria, carotid artery catheterization may require TFA or left TRA. 22,74 Left-sided transradial neurointerventions can also be challenging because of a lack of systems engineered for the forward load experienced and amount of proximal support required.…”