Abstract
Background
There has been debate in the literature regarding the adoption of a “radial-first” approach for mechanical thrombectomy (MT) in acute ischemic stroke (AIS). Conflicting reports suggest that transradial access (TRA) may allow for shorter times to reperfusion while others conclude that long-term functional outcomes may favor transfemoral access (TFA). Here, we report a single-institution experience with the adoption of TRA as the primary route for acute stroke intervention.
Methods
We retrospectively reviewed a single-institution database of patients undergoing MT for AIS from March 2020 to April 2023. This time period was selected to capture the change in clinical practice at our institution from TFA to TRA. Primary and secondary outcomes included technical success, procedural complications, and long-term functional outcomes. Patients were stratified into two cohorts from initial access. Cohorts were compared utilizing inferential statistics.
Results
A total of 192 consecutive cases were identified, with 80 in the TFA cohort and 112 in the TRA cohort. There was no difference in outcomes with respect to time from puncture to recanalization, rates of successful recanalization (TICI ≥ 2b), number of passes, rates of symptomatic intracranial hemorrhage (sICH), modified Rankin scale (mRS) at discharge and 90 days, and 90-day mortality (p ≥ 0.05, all). The TRA had a higher rate of access conversion (p < 0.001), while the TFA cohort had a higher rate of access site complications (p < 0.05).
Keywords: Acute ischemic stroke, endovascular, radial artery, thrombectomy, transradial access
Introduction
Transradial access (TRA) for neuroendovascular procedures has gained popularity due to a superior safety profile, decreased rate of access-site complications, and greater patient comfort compared to traditional transfemoral access (TFA).1–4 Feasibility of TRA for neurointerventional procedures has been described by several authors.3,5–7 In cases of AIS, time to revascularization is considered to be the most important factor influencing patient outcome. Increased familiarity with TFA among most neurointerventionalists is thought to decrease the time to reperfusion. Moreover, the greater caliber of the femoral artery allows for the use of catheters with a larger diameter. Recently, there has been significant debate in the literature regarding the adoption of a “radial-first” approach. Conflicting reports suggest that TRA may allow for shorter times to reperfusion while others conclude that long-term functional outcomes may favor TFA.5,8 In 2020, our institution gradually adopted TRA as the primary route for acute stroke intervention. We report a single-institution experience detailing patient demographics, periprocedural data, and long-term functional outcomes of both TFA and TRA cohorts.
Methods
Study population and inclusion criteria
Informed consent for the procedure was obtained from all patients or their proxies. Institutional Review Board approval was obtained prior to the onset of this study (STUDY2023-0418). We conducted a retrospective review of a prospectively maintained database of AIS stroke patients undergoing MT. Cases were performed from March 2020 to April 2023 to capture the change in practice after the adoption of a “radial-first” paradigm, wherein TRA has been attempted as a primary access site. All adult patients ≥ 18 years at presentation were screened for inclusion in the study. Patients were required to have a confirmed anterior or posterior large vessel occlusion (LVO) as demonstrated by computed tomography (CT) angiography, magnetic resonance (MR) angiography, or digital subtraction angiography with available clinical data related to the intervention. Functional outcomes were measured by the modified Rankin scale (mRS).
Patient demographics, periprocedural characteristics, complications, and clinical outcomes were collected. Demographics included age, sex, body mass index (BMI), race, and comorbidities of active smoking, hypertension, diabetes, atrial fibrillation, coronary artery disease, congestive heart failure, and prior history of ischemic stroke. Periprocedural characteristics included the National Institutes of Health Stroke Scale (NIHSS) at presentation and thrombolytic administration.
Procedural technique
Nearly all cases were performed with general anesthesia (GA) with 90% (72/80) of patients in the TFA undergoing thrombectomy with GA and all of the TRA cohort undergoing thrombectomy with GA. In cases of acute stroke interventions in the TRA group, both the wrist and the groin were prepped and draped in the usual sterile fashion. For patients presenting < 6 h from symptom onset and favorable ASPECTS score on CT scan, noninvasive vascular imaging was not obtained. For patients presenting between 6 and 24 h from symptom onset, CT perfusion was used to guide the decision for anterior circulation MT. Posterior circulation thrombectomy was performed based on confirmed large vessel occlusion on CT angiogram.
Transradial access
The right radial artery was accessed with or without ultrasound guidance based on operator preference. A thin-walled radial specific sheath measuring 7-French (Glidesheath Slender, Terumo, Japan) was introduced. The diameter of the radial artery was not routinely measured. Spasmolytic drugs were injected into the sheath at the operator's discretion, to a maximum of 5 mg verapamil and 200 μg nitroglycerin, aiming to keep the systolic blood pressure above 140 mm Hg in the setting of acute stroke. The 7F slender sheath was subsequently exchanged for a guide catheter, most commonly a 6F Flexor Shuttle (Cook Medical, Bloomington, Indiana, USA), to access the subclavian artery. The guide catheter was then coaxially navigated with a 5F Simmons-2 Select Diagnostic Catheter (Penumbra, Alameda, California, USA). In select cases, the Walrus balloon guide catheter (Q’Apel Medical, Fremont, California, USA) was used in a sheathless fashion. MT was performed by aspiration alone or by use of a stent-retriever and concurrent aspiration. At the end of the procedure, an external balloon compression device (TR-Band, Terumo, Japan) was used to achieve hemostasis.
Transfemoral access
The right common femoral artery was accessed with a micropuncture kit using either manual palpation or ultrasound guidance. A Bentson wire was inserted after which a guide sheath was introduced in exchange for the femoral sheath. The arteriotomy size ranged from 6 to 8 French although most commonly, a 6F Flexor Shuttle was used. In select cases, the Walrus balloon guide catheter was used. Guide catheter access to the carotid or vertebral arteries was performed using a coaxial system with either an angled tip or a Simmons-shaped catheter. MT was performed by aspiration alone or by use of a stent-retriever and concurrent aspiration. At the end of the procedure the arteriotomy was closed with Mynx grip (Cardinal Health, Dublin, Ohio, USA), the Angioseal device (Terumo, Tokyo, Japan), or manual pressure based on operator preference. In cases of intravenous thrombolytic administration prior to thrombectomy, the neurointerventionalist occasionally maintained the femoral sheath for 24 hours after the procedure with a heparinized flush before performing the arteriotomy closure in the intensive care unit.
Outcomes
Primary outcomes included puncture to reperfusion time, rates of successful recanalization (defined as ≥ TICI2b), and mRS score at 90 days. Secondary outcomes included an analysis of the number of passes, access site conversion rate, access site complications, and rates of sICH. Other procedural outcomes evaluated included room-to-intubation time, door-to-puncture time, door-to-start revascularization time, door-to-recanalization time, occlusion site, and number of passes. Data regarding the application of GA was also collected, namely ventilator-associated complications and duration of intubation. Patients with missing demographic, outcome, or follow-up data were excluded from analysis with the proportions of patients with available data reported in the accompanying tables. All outcomes were assessed in an intention-to-treat analysis.
Statistical analysis
Data were analyzed using Stata 18.0 (StataCorp, College Station, TX) at a significance value of 0.05 set a priori. Patients were separated into two cohorts based on initial attempted access: TFA or TRA. Student's t-test was utilized to compare cohorts for continuous variables. Chi-square analysis was utilized to compare cohorts for categorical variables.
Results
Patient cohort
A total of 192 consecutive patients underwent MT for LVO between March 2020 and April 2023. 80 patients underwent initial TFA and 112 patients underwent initial TRA. No significant differences were reported for NIHSS at presentation (TFA 16.30 ± 8.35 vs. TRA 14.43 ± 8.44) and rate of thrombolytic administration (TFA 32.5% (26) vs. TRA 31.3% (35)). The TFA cohort had higher rates of atrial fibrillation diagnosis (p = 0.008), while the TRA cohort reported higher rates of active smoking status (p = 0.008). No other significant differences were reported with respect to demographics and comorbidity status (Table 1).
Table 1.
Demographic and perioperative characteristics.
| Characteristic | Total (n = 192) | TFA (n = 80) | TRA (n = 112) | *p-value |
|---|---|---|---|---|
| Age (years) | 67.02 ± 12.98 (192) | 67.9 ± 12.19 (80) | 66.43 ± 13.54 (112) | 0.459 |
| Female | 48.4% (93/192) | 46.3% (37/80) | 50.0% (56/112) | 0.608 |
| BMI (kg/m2) | 29.09 ± 7.67 (189) | 27.89 ± 7.12 (78) | 29.94 ± 7.95 (111) | 0.071 |
| Race | 0.279 | |||
| White | 21.4% (41/192) | 21.3% (17/80) | 21.4% (24/112) | |
| Black | 53.1% (102/192) | 55.0% (44/80) | 51.8% (58/112) | |
| Hispanic | 1.6% (3/192) | 3.8% (3/80) | 0.0% (0/112) | |
| Asian | 6.3% (12/192) | 5.0% (4/80) | 7.1% (8/112) | |
| Other | 16.7% (32/192) | 15.0% (12/80) | 17.9% (20/112) | |
| Unspecified | 1.8% (2/192) | 0.0% (0/80) | 1.8% (2/112) | |
| Comorbidities | ||||
| Smoker | 31.4% (44/140) | 19.0% (11/58) | 40.2% (33/82) | 0.008 |
| Hypertension | 86.0% (159/185) | 89.7% (70/78) | 83.2% (89/107) | 0.204 |
| Diabetes | 37.4% (70/187) | 41.0% (32/78) | 34.9% (38/109) | 0.390 |
| Atrial fibrillation | 23.5% (44/187) | 33.3% (26/78) | 16.5% (18/109) | 0.008 |
| Coronary artery disease | 19.9% (37/186) | 15.4% (12/78) | 23.2% (25/108) | 0.191 |
| Congestive heart failure | 24.3% (45/185) | 22.4% (17/76) | 25.7% (28/109) | 0.605 |
| History of ischemic stroke | 24.2% (43/178) | 26.0% (19/73) | 22.9% (24/105) | 0.627 |
| NIHSS at presentation | 15.22 ± 8.43 (187) | 16.30 ± 8.35 (79) | 14.43 ± 8.44 (108) | 0.133 |
| IV thrombolytic administereda | 31.8% (61/192) | 32.5% (26/80) | 31.3% (35/112) | 0.854 |
| Occlusion site | 0.065 | |||
| Intracranial ICA | 16.2% (31/192) | 15.0% (12/80) | 17.0% (19/112) | |
| ICA with M1 involvement | 5.2% (10/192) | 7.5% (6/80) | 3.6% (4/112) | |
| M1 involvement alone | 33.9% (65/192) | 33.8% (27/80) | 33.9% (38/112) | |
| M2 | 19.8% (38/192) | 13.8% (11/80) | 24.1% (27/112) | |
| ICA with M1 + M2 involvement | 5.2% (10/192) | 3.8% (3/80) | 6.3% (7/112) | |
| M1 + M2 involvement | 1.1% (2/192) | 0.0% (0/80) | 1.8% (2/112) | |
| Posterior circulation | 15.1% (29/192) | 23.8% (19/80) | 8.9% (10/112) | |
| Other | 3.7% (7/192) | 2.5% (2/80) | 4.5% (5/112) |
TFA: transfemoral access; TRA: transradial access; BMI: body mass index; NIHSS: National Institutes of Health Stroke Scale; IV: intravenous; tPA: tissue plasminogen activator; ICA: internal carotid artery; M1: first segment of middle cerebral artery; M2: second segment of middle cerebral artery.
a8% (2/26) patients in the TFA group underwent tenecteplase administration and 92% (24/26) were given alteplase. 17% (6/35) of patients in the TRA group underwent tenecteplase administration and 83% (29/35) were given alteplase.
*p-value calculated using Student's t-test for continuous variables and chi-square analysis for categorical variables.
Boldface indicates significance (p < 0.05).
Clinical outcomes
There was no statistically significant difference with respect to primary outcome measures between the TFA and TRA groups (Table 2). Puncture to reperfusion time was 32.64 ± 23.50 min in the TFA group and 37.38 ± 23.88 min in the TRA group. Rates of successful recanalization in the TFA and TRA groups were 91.3% (73) and 92.9% (104), respectively. There was also no statistically significant difference in mRS score at 90 days (p = 0.566, Figure 1).
Table 2.
Outcome measures.
| Characteristic | Total (n = 192) | TFA (n = 80) | TRA (n = 112) | *p-value |
|---|---|---|---|---|
| Time in room to intubation (min) | 20.79 ± 29.61 (167) | 22.10 ± 40.24 (61) | 20.04 ± 21.43 (106) | 0.666 |
| Door to puncture (min) | 70.60 ± 94.50 (189) | 61.56 ± 49.86 (79) | 77.09 ± 116.28 (110) | 0.266 |
| Door to start of revascularization (min) | 91.42 ± 97.61 (189) | 79.67 ± 51.75 (79) | 99.85 ± 119.76 (110) | 0.161 |
| Door to recanalization (min) | 104.90 ± 99.27 (185) | 94.92 ± 54.22 (79) | 112.34 ± 122.28 (106) | 0.239 |
| Puncture to recanalization (min) | 35.37 ± 23.77 (184) | 32.64 ± 23.50 (78) | 37.38 ± 23.88 (106) | 0.182 |
| Successful recanalization (TICI ≥ 2B) | 92.2% (177/192) | 91.3% (73/80) | 92.9% (104/112) | 0.682 |
| Number of passes | 1.92 ± 1.06 (190) | 2.02 ± 1.15 (79) | 1.84 ± 1.00 (111) | 0.233 |
| Access conversion rate | 10.4% (20/192) | 1.3% (1/80) | 17.0% (19/112) | <0.001 |
| Overall access site complications | 10.5% (20/192) | 17.5% (14) | 5.4% (6) | 0.007 |
| Access site complications | ||||
| Hematoma | 8.9% (17/192) | 13.8% (11/80) | 5.4% (6/112) | 0.044 |
| Limb Ischemia | 0.5% (1/192) | 1.3% (1/80) | 0.0% (0/112) | 0.236 |
| Othera | 1.0% (2/192) | 2.5% (2/80) | 0.0% (0/112) | 0.093 |
| sICH | 3.6% (7/192) | 3.8% (3/80) | 3.6% (4/112) | 0.948 |
| Total intubation time (hours) | 18.03 ± 36.10 (153) | 23.48 ± 5.71 (54) | 15.06 ± 32.30 (99) | 0.169 |
| Ventilator-associated complications | 5.8% (9/156) | 3.6% (2/56) | 7.0% (7/100) | 0.378 |
| 90-Day mRS | 0.566 | |||
| 0 | 6.0% (10/168) | 6.8% (5/74) | 5.3% (5/94) | |
| 1 | 22.6% (38/168) | 18.9% (14/74) | 25.5% (24/94) | |
| 2 | 8.3% (14/168) | 10.8% (8/74) | 6.4% (6/94) | |
| 3 | 14.9% (25/168) | 13.5% (10/74) | 16.0% (15/94) | |
| 4 | 11.9% (20/168) | 8.1% (6/74) | 14.9% (14/94) | |
| 5 | 8.3% (14/168) | 9.5% (7/74) | 7.5% (7/94) | |
| 6 | 28.0% (47/168) | 32.4% (24/74) | 24.5% (23/94) | |
| 90-Day mortality | 17.9% (30/168) | 20.3% (15/74) | 16.0% (15/94) | 0.469 |
TFA: transfemoral access; TRA: transradial access; TICI: Thrombolysis in Cerebral Infarction Scale; sICH: symptomatic intracranial hemorrhage mRS: modified Rankin scale.
Access site complications were due to two instances of femoral thrombus formation.
*p-value calculated using Student's t-test for continuous variables and chi-square analysis for categorical variables.
Boldface indicates significance (p < 0.05).
Figure 1.
Distribution of modified Rankin scale scores at 90 days in the intention-to-treat groups. Scores range from 0 to 6 with 0 indicating no symptoms and 6 indicating death. There was no statistically significant overall difference between the TFA and TRA groups (p = 0.566).
TRA: transradial access; TFA: transfemoral access.
The TRA cohort underwent access site conversion at a higher rate than the TFA cohort (TFA 1.3% (1) vs. TRA 17.0% (19), p < 0.001). All access site complications were reported, including hematomas requiring no further intervention, and were significantly less frequent in the TRA group (TFA 17.5% (14) vs. TRA 5.4% (6)). There was no statistically significant difference noted in other outcome measures including number of passes, rate of sICH, intubation time, ventilator-associated complications, mRS at discharge, and 90-day mortality. Forest plots for primary and secondary outcome measures are provided, measuring the odds ratio and standardized mean difference for categorical and continuous variables respectively (Figure 2). A case example of a left M2 occlusion successfully treated via the TRA is demonstrated in Figure 3.
Figure 2.
Forest plots depicting primary and secondary outcome measures. Odds ratios are shown for categorical outcome measures (A) and standardized mean differences are shown for continuous outcome measures (B) with 95% confidence intervals. Access site conversion was observed more frequently in the TRA group while access site complications were observed more frequently in the TFA group. There was no statistically significant difference with respect to other outcome variables.
TRA: transradial access; TFA: transfemoral access.
Figure 3.
An example case of successful reperfusion via the transradial approach. A 70-year-old female with a history of atrial fibrillation on rivaroxaban presented with aphasia and right hemiparesis upon awakening from sleep. Thrombolysis was contraindicated due to active anticoagulant use and time of symptom onset > 4.5 hours. The NIHSS score was 14 and imaging demonstrated a left M2 occlusion with a 79cc penumbra and no ischemic core (A). Using a transradial approach, the catheter system was successfully navigated to the left side (B). The patient underwent mechanical thrombectomy with aspiration alone yielding TICI 3 revascularization after one pass (C and D).
NIHSS: National Institutes of Health Stroke Scale; TICI: Thrombolysis in Cerebral Infarction Scale.
Discussion
In the present study, we compared the outcomes and complications associated with an initial TRA compared to standard TFA for MT in AIS. The specific time period was selected to capture the change in practice from TFA to TRA at our institution. The two cohorts of patients were well-balanced with respect to demographics and perioperative characteristics. We found that initial TRA had higher rates of access site conversion, while initial TFA demonstrated higher rates of access site complications. Our study considered all radial and femoral hematomas ≥ 1 cm as access site complications irrespective of the need for further procedures. All hematomas in both patient cohorts were self-resolved and did not require further intervention. Importantly, there was no statistically significant difference in the primary outcome measures of puncture to reperfusion time, rate of successful recanalization, and mRS at 90 days. These findings indicate that in the setting of acute stroke intervention, TRA is non-inferior to TFA and may offer the benefit of reduced access site complications.
While TRA is gaining popularity in neurointervention, one limitation relates to the inherently small caliber of the radial artery. This restricts the use of larger guide catheters which becomes relevant in the treatment of AIS where most large-bore aspiration catheters require a guide catheter internal diameter (ID) of 0.088″. The delivery of such large guide catheters via the radial artery causes patient discomfort, pain, and vasospasm. As such, this technique may not be well tolerated by the awake patient under conscious sedation. Anecdotally, this has been our experience when TRA was attempted in awake patients undergoing MT, occasionally requiring the intervention to be performed using a smaller guide sheath with a resultant limitation in the size of the aspiration catheter to 5F. We suspect that the results noted by Siddiqui et al. in their study, namely unfavorable rates of revascularization and functional outcomes in the TRA group, were in part due to this technical limitation as well as a higher proportion of patients in the TRA group undergoing stent-only MT. 8
In the early stages of the coronavirus disease 2019 (COVID-19) pandemic, our institution transitioned to performing AIS interventions under GA due to the benefits of closed-circuit ventilation. 9 Concurrently, we began performing diagnostic arteriography and endovascular interventions via the radial approach with increasing frequency. In a short period of time, MT for AIS was routinely performed under GA with a “radial-first” paradigm. With GA, patient comfort is maximized, thereby reducing catheter-related vasospasm. This in turn has facilitated the use of larger guide catheters via the radial artery. Our technique, employing a 7F introducer sheath followed by an exchange for a 6F long sheath, allows for the use of several commonly available large-bore aspiration catheters with an ID ranging from 0.068 to 0.072″. Pooled data from randomized clinical trials (RCTs) comparing GA and conscious sedation in AIS interventions has shown higher rates of successful recanalization and functional independence in the cohort undergoing GA.10,11 We found that in the majority of patients with uncomplicated anterior circulation thrombectomy, extubation was performed upon conclusion of the procedure. Taking into consideration increased patient comfort combined with the aforementioned data regarding functional outcomes, the case for utilization of GA is strengthened.
Aortic arch anatomy remains a principal consideration when performing interventions via the transradial route, particularly in time-sensitive procedures. Our data indicates a high rate of conversion from TRA to TFA. We believe this to be due to in part, the 90 cm length of most readily-available guide catheters. This can be a limitation when accessing a high cervical internal carotid artery (ICA) in patients with arch tortuosity or ICA dolichoarteriopathy as the catheter ends up short in the common carotid artery. Less guide catheter support can negatively impact the efficacy of the intervention. The most common reason for access site conversion in our study was difficulty advancing the guide sheath to address left-sided pathology in patients with a tortuous aortic arch. In a few cases, the guide sheath could not be advanced past the radial or subclavian arteries due to vasospasm. When time is of the essence, we believe converting to TFA early can lead to similar revascularization rates within an acceptable time frame. In the setting of posterior circulation stroke (PCS) with a poorly accessible right vertebral artery (VA), left radial access also represents a viable approach to the dominant left VA. Other authors have described a tailored approach, selecting the route of access based on patient anatomy or site of occlusion with comparable clinical outcomes between TRA and TFA groups.12–14 Notable anatomic features well-suited for TRA include left anterior LVO with a bovine arch, type 2 or 3 arches, PCS with a favorable angle of access to the right VA, and patients with anatomy rendering TFA challenging such as aortoiliac disease, pregnancy and obesity.
Our results certainly mirror those of other retrospective studies in the literature. Munich et al., Khanna et al., and Phillips et al. conducted retrospective analyses comparing TFA and TRA at their respective centers.1,5,15 All noted no difference with respect to rates of successful reperfusion and functional outcomes. In all three studies, TFA was associated with greater rates of access site complications although only one was powered sufficiently to render this statistically significant. More recently, a noninferiority RCT comparing TFA with TRA in MT for AIS demonstrated noninferiority of the radial approach with similar rates of final recanalization and 90-day mRS despite longer procedural times in the TRA cohort. 16 The Stroke Thrombectomy and Aneurysm Registry (STAR) was recently reviewed to compare TRA versus TFA specifically in the ICA and M1 segment of the middle cerebral artery LVO. 17 In contrast to the aforementioned RCT, reperfusion time in the TRA group was found to be significantly shorter. While rates of ≥ TICI 2b revascularization did not differ between groups, multivariate analysis showed higher rates of ≥ TICI 2c and TICI3 revascularization in the TRA group. However, functional outcomes did not differ between groups.
Conclusions
In this study, we found TFA and TRA to be comparable with respect to the clinical and periprocedural outcomes of time to reperfusion, rate of successful recanalization, and long-term functional status. TRA was associated with a greater rate of access site conversion while access site complications were more common with TFA. Taken together, these findings suggest that the radial approach achieves similar clinical efficacy while offering the benefit of less access site complications. Performing MT with GA may facilitate delivery of larger guide catheters via the radial artery and careful review of pre-procedural imaging may identify anatomic features well-suited for the radial approach.
Footnotes
Data availability statement: The authors confirm that the data supporting the findings of this study are available within the article.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval and informed consent statement: Institutional Review Board approval was obtained prior to the onset of this study (STUDY2023-0418). Informed consent for the procedure was obtained from either the patient or proxy.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Richard Bram https://orcid.org/0000-0001-8377-9192
Ali Alaraj https://orcid.org/0000-0002-1491-4634
References
- 1.Khanna O, Sweid A, Mouchtouris N, et al. Radial artery catheterization for neuroendovascular procedures. Stroke 2019; 50: 2587–2590. [DOI] [PubMed] [Google Scholar]
- 2.Snelling BM, Sur S, Shah SS, et al. Transradial cerebral angiography: techniques and outcomes. J Neurointerv Surg 2018; 10: 874–881. [DOI] [PubMed] [Google Scholar]
- 3.Snelling BM, Sur S, Shah SS, et al. Transradial access: lessons learned from cardiology. J Neurointerv Surg 2018; 10: 487–492. [DOI] [PubMed] [Google Scholar]
- 4.Ferrante G, Rao SV, Jüni P, et al. Radial versus femoral access for coronary interventions across the entire spectrum of patients with coronary artery disease: a meta-analysis of randomized trials. JACC Cardiovasc Interv 2016; 9: 1419–1434. [DOI] [PubMed] [Google Scholar]
- 5.Phillips TJ, Crockett MT, Selkirk GD, et al. Transradial versus transfemoral access for anterior circulation mechanical thrombectomy: analysis of 375 consecutive cases. Stroke Vasc Neurol 2021; 6: 207–213. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Khanna O, Velagapudi L, Das S, et al. A comparison of radial versus femoral artery access for acute stroke interventions. J Neurosurg 2020; 135: 727–732. doi:10.3171/2020.7.JNS201174 [DOI] [PubMed] [Google Scholar]
- 7.Snelling BM, Sur S, Shah SS, et al. Transradial approach for complex anterior and posterior circulation interventions: technical nuances and feasibility of using current devices. Oper Neurosurg (Hagerstown) 2019; 17: 293–302. [DOI] [PubMed] [Google Scholar]
- 8.Siddiqui AH, Waqas M, Neumaier J, et al. Radial first or patient first: a case series and meta-analysis of transradial versus transfemoral access for acute ischemic stroke intervention. J Neurointerv Surg 2021; 13: 687–692. [DOI] [PubMed] [Google Scholar]
- 9.Su WL, Hung PP, Lin CP, et al. Masks and closed-loop ventilators prevent environmental contamination by COVID-19 patients in negative-pressure environments. J Microbiol Immunol Infect 2021; 54: 81–84. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Zhang Y, Jia L, Fang F, et al. General anesthesia versus conscious sedation for intracranial mechanical thrombectomy: a systematic review and meta-analysis of randomized clinical trials. J Am Heart Assoc 2019; 8: e011754. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Schönenberger S, Hendén PL, Simonsen CZ, et al. Association of general anesthesia vs procedural sedation with functional outcome among patients with acute ischemic stroke undergoing thrombectomy: a systematic review and meta-analysis. JAMA 2019; 322: 1283–1293. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Barranco-Pons R, Caamaño R, Guillen AN, et al. Transradial versus transfemoral access for acute stroke endovascular thrombectomy: a 4-year experience in a high-volume center. Neuroradiology 2022; 64: 999–1009. [DOI] [PubMed] [Google Scholar]
- 13.Chen SH, Snelling BM, Sur S, et al. Transradial versus transfemoral access for anterior circulation mechanical thrombectomy: comparison of technical and clinical outcomes. J Neurointerv Surg 2019; 11: 874–878. [DOI] [PubMed] [Google Scholar]
- 14.Verhey LH, Orozco AR, Oliver M, et al. Transradial versus transfemoral access for mechanical thrombectomy in acute ischemic stroke: a retrospective cohort study. J Stroke Cerebrovasc Dis 2023; 32: 107282. [DOI] [PubMed] [Google Scholar]
- 15.Munich SA, Vakharia K, McPheeters MJ, et al. Transition to transradial access for mechanical thrombectomy—lessons learned and comparison to transfemoral access in a single-center case series. Oper Neurosurg (Hagerstown) 2020; 19: 701–707. [DOI] [PubMed] [Google Scholar]
- 16.Hernandez D, Requena M, Olivé-Gadea M, et al. Radial versus femoral access for mechanical thrombectomy in patients with stroke: a noninferiority randomized clinical trial. Stroke 2024; 55: 840–848. [DOI] [PubMed] [Google Scholar]
- 17.Silva MA, Elawady SS, Maier I, et al. Comparison between transradial and transfemoral mechanical thrombectomy for ICA and M1 occlusions: insights from the Stroke Thrombectomy and Aneurysm Registry (STAR). J Neurointerv Surg 2024. DOI: 10.1136/jnis-2023-021358 [DOI] [PubMed] [Google Scholar]