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. 2025 Apr 4:15910199251330120. Online ahead of print. doi: 10.1177/15910199251330120

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

Navpreet K Bains 1, Mohamad Ezzeldin 2,✉, Ibrahim A Bhatti 1, Adam Delora 3, Adnan I Qureshi 1, Rime Ezzeldin 4, Ameer E Hassan 5, M Shazam Hussain 6, Faheem G Sheriff 7, Gustavo J Rodriguez 7, Alberto Maud 7, Ramesh Grandhi 8, Ali Alaraj 9, Chizoba Ezepue 10, Amer Alshekhlee 10, Omar Tanweer 11, Ossama Mansour 12, Saif Bushnaq 13, Peter Kan 14, Nazli Janjua 15, Kaiz S Asif 16, Muhammad Niazi 17, Varun Chaubal 18, Tunmi Anwoju 19, Zuhair Ali 19, Leighann Mealer 2, Maria Martucci 6, Samantha Miller 5, Mohammad A Abdulrazzak 6, Saqib Shaikh 7, Walid K Salah 8, Elsa Nico 9, Oz Haim 11, Mohammad AlMajali 18, Gautam Edhayan 14, Musaab Froukh 16, Osama O Zaidat 18, Farhan Siddiq 20
PMCID: PMC11977619  PMID: 40183400

Abstract

Background and purpose

The 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 methods

Multicenter 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.

Results

1346 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.

Conclusion

Both 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.

Keywords: Transradial, transfemoral, extracranial carotid artery stenting, computed tomography angiography, magnetic resonance angiography

What is already known on this topic

The transfemoral (TF) approach has traditionally been the standard for extracranial carotid artery stenting (eCAS). In contrast, the transradial (TR) approach has gained popularity due to its potential benefits, such as reduced complications and shorter recovery times. However, limited understanding exists regarding how anatomical and geometric factors influence the success rates of these approaches, highlighting the need for targeted research.

What this study adds

This study identifies the angle of origin of the left common carotid artery as a significant predictor of complications associated with the TR approach. Importantly, it finds no other anatomical features or great vessel geometries that predict complications or conversion rates.

How this study might affect research, practice, or policy

The findings suggest that neurointerventionalists should consider specific anatomical characteristics when selecting between TR and TF approaches for eCAS. This could lead to more individualized treatment strategies, reduced conversion rates, and improved patient safety, ultimately influencing future research directions and clinical guidelines in neurointerventional procedures.

Introduction

The transradial (TR) approach is an alternative to the traditional transfemoral (TF) approach for neuroendovascular procedures and has been growing in popularity recently.1–3 The TR approach has demonstrated reduced procedure time, better safety outcomes, greater patient satisfaction, and reduced hospitalization.1,4,5 Although the TR approach to neuroendovascular diagnostic and interventional procedures confers more than a 90% success rate, conversion to the TF approach is sometimes warranted.6,7 While intended to reduce procedure time, conversion from TR to TF approach may contribute to longer procedure time. The conversion to the TF approach is attributed to the tortuosity and geometry of the right subclavian and the carotid artery, the type of aortic arch, and the tortuosity and spasm of the radial artery.4,7–9 Therefore, analyzing the geometry of the great vessels and aortic arch angles may help select patients with favorable anatomy to undergo a successful TR approach and minimize conversion to the TF approach.

We aim to study great vessel geometry and aortic arch angles and their effect on the predictability of success of the TR approach in non-emergent extracranial carotid artery stenting (eCAS) compared to the TF approach. We also analyzed the overall complications of eCAS and performed a sub-analysis to assess whether various anatomical features correlate with complications. We also compared the operational efficacy of both approaches in elective eCAS.

Methods

This is a multi-center retrospective study of patients who underwent elective eCAS. IRB approval was individually attained at each involved site. Patients who underwent elective eCAS from January 2018 to December 2022 were included in the study. We collected demographics of age, gender, and medical comorbidities. Diagnostic non-invasive imaging, including computed tomography angiography (CTA) or magnetic resonance angiography (MRA), head and neck, were utilized for intervention planning. The following geometric parameters deemed to affect catheter navigation were measured on CTA or MRA and analyzed: tortuosity of the right subclavian artery measured as an angle (A), angle of origin (A2) of right common carotid artery (RCCA) from the brachiocephalic trunk, distance (D1) between the origin of RCCA and right internal carotid artery (RICA), distance (D5) between the origin of brachiocephalic trunk and left common carotid artery (LCCA) from the aortic arch, tortuosity at the origin of the LCCA measured as an angle (C), angle of origin of LCCA from the aortic arch (A3), the distance (D2) between the origin of LCCA and left internal carotid artery (LICA) and the type of aortic arch were measured (Figures 1 and 2). Figure 3 provides an additional example and also illustrates the use of 3D construction CTA images to guide measurements of tortuous anatomy. The success of the TR approach was defined as the successful completion of carotid artery stenting without TF conversion.

Figure 1.

Figure 1.

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Aortic arch and geometry of the great vessels in consideration for transradial approach to elective extracranial carotid artery stenting. Tortuosity of the right subclavian artery measured as an angle (A), angle of origin (A2) of right common carotid artery from the brachiocephalic trunk, distance (D1) between the origin of right common carotid and right internal carotid artery, distance (D5) between the origin of brachiocephalic trunk and left common carotid artery on the aortic arch, tortuosity at the origin of the left common carotid artery measured as an angle (C), angle of origin of left common carotid artery from the aortic arch (A3), and distance (D2) between the origin of left common carotid and left internal carotid artery were measured and analyzed.

Figure 2.

Figure 2.

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Clinical examples of geometric measurements on CTA on two different patients: tortuosity of the right subclavian artery measured as an angle (A) and angle of origin of left common carotid artery from the aortic arch (A3) in panel A, tortuosity at the origin of the left common carotid artery measured as an angle (C) in panel B, angle of origin (A2) of right common carotid artery from the brachiocephalic trunk, distance (D1) between the origin of right common carotid and right internal carotid artery and distance (D2) between the origin of left common carotid and left internal carotid artery in panel C, and distance (D5) between the origin of brachiocephalic trunk and left common carotid artery on the aortic arch in panel D.

Figure 3.

Figure 3.

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Geometric parameters of patient with A3 angle < 90° who succumbed to complications during their carotid treatment. During the procedure, vascular access was converted from radial to femoral. The patient sustained a right subclavian artery dissection extending into the aortic arch culminating in cardiac arrest and death. 3D CTA reconstruction images can supplement understanding of the geometric parameters and subsequent measurements on 2D CTA, panel F.

Complications were divided into Category 1, defined as 30-day periprocedural mortality, symptomatic stroke, intracerebral hemorrhage, or myocardial infarction, and Category 2, defined as non-periprocedural mortality, asymptomatic intracranial hemorrhage, transient ischemic attack, and distal embolization addressed intra-procedurally with no neurological deficits.

Statistical analysis

The geometric data was analyzed with logistic regression using statsmodels 0.14.1 with the dependent variables of complications, stent laterality, and access site conversion. Wilcoxon rank-sum test was performed on continuous variables, and Chi-Square tests were performed on categorical variables, using Scipy Stats 1.9.1 to assess for complications and access site conversions.10–12 We also conducted a sensitivity analysis to account for patients who did not have a follow-up at >30 days and who could have had a procedural complication (n = 136) we did not account for. The sensitivity analysis was performed with three different scenarios: assuming these patients had no complications, removing these patients altogether, or utilizing a multivariate feature imputation. When data was returned from the multivariate feature imputation model, the complications column with a value greater than 0.5 was considered a complication, and those less than 0.5 were classified as no complication. This sensitivity analysis was performed using Scikit-learn 1.3.2. 11 The analysis of the angles was performed using multivariate logistic regression, but due to the exploratory nature of the study, we did not formally adjust for multiple comparisons between several multivariate and univariate statistical tests being performed, but interpreted our findings considering the many tests being performed. A Chi-squared test was performed to determine if there was a relationship between aortic arch type and complications. A Wilcoxon Rank Sum Test was used to determine the difference in procedure time in the TR versus TF approach.

Results

A total of 1446 patients were recruited from 17 hospitals who underwent elective extracranial carotid stenting. Vascular, endovascular fellows or staff who were blinded to the results at the participating sites performed the geometric measurements; complex and questionable measurements were further ascertained by the primary and senior authors (NB, ME, and FS). Sites that did not participate (n = 1) or did not perform carotid artery stenting via transradial approach (n = 1) were excluded from the study. Patients with missing non-invasive evaluation of aortic arch anatomy or poor image quality precluding from adequate assessment of the aortic arch were also excluded from the analysis. 1346 patients were included in the analysis (Figure 4). 1081 patients (80.08%) underwent the TF approach, and 265 (19.69%) underwent the TR approach; 44 (17%) of the TR approaches were converted to the TF approach, and 3 (0.3%) of the TF approaches were converted to TR approach. Among the 1346 patients, there were a total of 57 (4.23%) patients with complications. Some of these patients sustained multiple complications that were in different categories. 24 (1.78%) patients sustained Category 1 complications, and 38 (2.82%) patients sustained Category 2 complications. A subanalysis was performed on a subset of patients with imaging that was high enough quality to make measurements on the aortic arch. There were 283 patients in this subanalysis and 12 patients with complications. Of these patients, there were only five patients with a category 1 complication and nine patients with a category 2 complication. Again, several patients had complications of more than one category. Female (P = .032) and elderly (P = .004) patients were more likely to have complications. While most patients did not require access site conversion, conversion from the TR to TF approach predicted a 1% increased rate of general anesthesia. These patients were more likely to have complications (P = .043), particularly Category 1 complications (P < .001). A higher preprocedural NIHSS stroke scale (P = .039), increased contrast (P = .018), and a longer procedure time (P = .002) also predicted a higher increased rate of access site conversion. Summary statistics and complications are shown in (Table 1). We found there was no statistically significant difference in the overall complication rate between transfemoral and transradial access (P = .773).

Figure 4.

Figure 4.

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Flow chart of patient selection from the total number of patients to patients who underwent transfemoral (TF) extracranial carotid artery stenting (eCAS), transradial (TR) eCAS, TR to TF conversion, and TF to TR conversion.

Table 1.

Patient demographics and their association with overall complications. Complications included periprocedural mortality, symptomatic ischemic or hemorrhagic stroke, myocardial infarction, non-periprocedural mortality, asymptomatic intracranial hemorrhage, transient ischemic attack, and distal embolization addressed intra-procedurally with no neurological deficits.

Characteristics Number (n) Percent (%) All complications Complications (%) P value
Sex 0.032
Male 875 65 29 3.3
Female 471 35 28 5.9
Race 0.36
White 967 72 36 3.7
Black 177 13 9 5.6
Hispanic 161 12 11 6.2
Other 35 2.6 1 2.9
Diabetes mellitus 0.123
No 805 60 28 3.5
Yes 541 40 29 5.4
Hypertension 0.423
No 177 13 5 2.8
Yes 1168 87 52 4.5
Atrial fibrillation 0.352
No 1173 87 47 4.0
Yes 170 13 10 5.9
Hyperlipidemia 0.903
No 332 25 15 4.5
Yes 1009 75 42 4.2
Congestive heart failure 0.539
No 1174 87 47 4.9
Yes 168 13 9 5.4
Prior stroke 0.251
No 626 47 21 3.4
Yes 716 53 34 4.8
Smoking 0.267
Never Smoker 445 33 21 4.7
Previous Smoker 538 40 26 4.8
Current Smoker 361 27 10 2.8
Alcohol use 0.713
No 794 62 35 4.4
Yes 497 39 19 3.8
Prior myocardial infarction 0.117
No 1108 82 42 3.8
Yes 238 18 15 6.3
Access sheath 0.773
Femoral 1078 80 47 4.4
Radial 268 20 10 3.7
Aortic arch type 0.11
1 670 55 21 3.1
2 336 27 15 4.5
3 223 18 14 6.3
Complications 57 4.2
Type 1 24 1.8
Type 2 48 2.8
Laterality 0.999
Left 715 54 30 52.6
Right 621 46 27 47.4
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There was no statistically significant relationship between aortic arch type and complications when stratified into TR (P = .158) and TF (P = .103) approaches. There were proportionally more complications in type 2 (5.55%) and 3 (5.85%) aortic arch types versus type 1 (2.93%), but these results were not statistically significant. In patients who underwent the TR approach the type of aortic arch did not correlate with access site conversion rate or carotid laterality. The TR approach took, on average, 4.26 min longer than the TF approach.

A sub-analysis was performed to ascertain if the various anatomical features, including angles such as A, A2, A3, and C, and distances such as D1, D2, and D3, correlated with complications. A total of 283 patients, 241 with transradial and 42 with transfemoral approach with accessible aortic arch imaging, were included in this sub-analysis. The angle of the left common carotid artery origin with respect to the aortic arch, A3, correlated with complications, which became even more significant when the type of access was further stratified into TR versus TF (Table 2). Furthermore, a smaller angle A3 was associated with patient complications. Based on the distribution of the complications, most of the complications occur around an A3 angle of 50°, with a sharp increase at less than 90°. Figure 3 provides a clinical example of a patient with A3 < 90° who succumbed to their complications.

Table 2.

Various anatomical factors and their association with complications during elective carotid artery stenting. Tortuosity of the right subclavian artery (A), angle of origin (A2) of RCC artery from the brachiocephalic trunk, distance (D1) between the origin of RCC and RICA, distance (D5) between the origin of brachiocephalic trunk and LCC artery from the aortic arch, tortuosity at the origin of the LCC (C), angle of origin of LCC from the aortic arch (A3), the distance (D2) between the origin of LCC and LICA.

Anatomical variable Coef Std err z P-value [0.025] [0.975]
Angle A (degrees) 0.0055 0.013 0.425 .671 −0.02 0.031
Angle A2 (degrees) 0.0037 0.013 0.278 .781 −0.02 0.030
Angle A3 (degrees) 0.0160 0.008 −2.061 .039 −0.031 −0.001
Angle C (degrees) 0.0100 0.008 1.173 .241 −0.027 0.007
Distance D1 (mm) 0.0020 0.019 0.105 .916 0.036 0.040
Distance D2 (mm) 0.0206 0.016 1.266 .205 −0.052 0.011
Distance D5 (mm) 0.0472 0.052 0.903 .366 −0.15 0.055
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Left-sided stents were more likely to be placed from a femoral sheath (56.50%), and right-sided stents were more likely to be placed radially (58.42%). There was no statistically significant difference in stent laterality (left versus right-sided stent placement) and complications (P = .999) or access site conversion (P = .124). Moreover, we found there to be no significant deterministic effect of vessel dimensions and geometry on the success of either approach (Tables 3 and 4).

Table 3.

Success of carotid artery stenting via transradial approach as it relates to the laterality of the carotid artery being treated. The angles such as A, A2, A3, and C and distances such as D1, D2, and D5 did not correlate with success of the carotid artery stenting via transradial approach. Tortuosity of the right subclavian artery (A), angle of origin (A2) of RCC artery from the brachiocephalic trunk, distance (D1) between the origin of RCC and RICA, distance (D5) between the origin of brachiocephalic trunk and LCC artery from the aortic arch, tortuosity at the origin of the LCC (C), angle of origin of LCC from the aortic arch (A3), the distance (D2) between the origin of LCC and LICA.

Anatomical variable Coef Std err z P>|z| [0.025 0.975]
Angle A (degrees) −0.0022 0.005 −0.403 .687 −0.013 0.008
Angle A2 (degrees) 0.0025 0.006 0.411 .681 −0.009 0.014
Angle A3 (degrees) −0.0004 0.003 −0.141 .888 −0.006 0.005
Angle C (degrees) −0.0012 0.004 −0.324 .746 −0.009 0.006
Distance D1 (mm) 0.0033 0.005 0.64 .522 −0.007 0.013
Distance D2 (mm) 0.0054 0.005 1.07 .284 −0.004 0.015
Distance D5 (mm) 0.0084 0.018 0.457 .648 −0.028 0.044
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Table 4.

Correlation of access site conversion with anatomical features including tortuosity of the right subclavian artery (a), angle of origin (A2) of RCC artery from the brachiocephalic trunk, distance (D1) between the origin of RCC and RICA, distance (D5) between the origin of brachiocephalic trunk and LCC artery from the aortic arch, tortuosity at the origin of the LCC (c), angle of origin of LCC from the aortic arch (A3), the distance (D2) between the origin of LCC and LICA. The various anatomical features described above do not correlate with access site conversion (i.e., these angles and distances do not matter with regard to access site conversion).

Anatomical variable Coef Std err z P>|z| [0.025 0.975]
Angle A (degrees) −0.0005 0.007 −0.073 .942 −0.014 0.013
A2 arch (degrees) −0.0068 0.008 −0.909 .363 −0.022 0.008
A3 arch (degrees) −0.0034 0.004 −0.924 .355 −0.01 0.004
Angle C (degrees) −0.0057 0.005 −1.186 .236 −0.015 0.004
Distance D1(mm) 0.0022 0.008 0.272 .786 −0.014 0.018
Distance D2 (mm) −0.0026 0.007 −0.368 .713 −0.016 0.011
Distance D5 (mm) −0.0376 0.028 −1.352 .176 −0.092 0.017
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Discussion

The TR approach in neurointerventions has recently gained popularity, with the emerging literature supporting its feasibility, safety, and efficacy.7,13,14 Several patient factors, including more comfort, less access site complications, shorter post-procedural stay, and early immobility, have popularized the TR approach over the TF approach. 15 Despite similar complication rates between the TR and TF approaches, the TR approach portends approximately a 5–15% conversion rate to the TF approach to complete the intended procedure, adding to the overall procedure time.6,16,17 The most commonly cited reasons for TR to TF conversion are vessel tortuosity, lack of support catheter system, and small caliber radial artery. 17 Interestingly, the TR approach has a higher success rate in bovine and type 3 arch anatomy than the TF approach, and the TF approach with the bovine and type 3 arch results in longer procedural times.18,19 The most common conversion occurred during left-sided stents in one analysis. 20 Our study shows that patients who undergo conversion suffer category 1 complications more commonly. Even though laterality was not associated with conversion rates in our analysis, we did find that smaller angles of the left common carotid origin are also associated with complications.

Several studies have suggested reviewing great vessel anatomy prior to procedures to minimize conversion rates, but no clear determinants of eCAS failure have been identified. Moreover, recent advances and focus on TR-compliant catheters have increased the need to study anatomic features in greater detail. Zerebiec et al. analyzed various anatomical features of the aortic arch and branching from the parent arteries and catheterization with the Simmons 2 diagnostic catheter. 4 While successful and selective catheterization of the desired carotid artery with a Simmons 2 diagnostic catheter is enhanced by an understanding of its geometry and vectors, navigating and advancement of a guide access catheter into the distal common carotid artery was historically limited by the lack of TR specific guide access catheters.4,21 Guide access catheters designed for TF access were previously utilized for the TR approach, which is sometimes not prone to smooth navigability, especially across acute angles due to its distal stiffness required for transfemoral navigation that is seen in acute angle take off of right common carotid artery from the brachiocephalic trunk (A2) or acute angle take-off of the left common carotid artery from the aortic arch (A3). For these reasons, the association between angles A and A2 and the rate of transfemoral conversion for right carotid stenting, and the association between distance D and angle A3 and the rate of TF conversion for left carotid stenting was anticipated. However, no such correlation was concluded in our analysis. The lack of such correlation may be due to the introduction of more TR-specific access guide sheaths such as BMX (Penumbra Inc., Alameda, CA), RIST (Medtronic, Minneapolis, MN), and Zoom Radial Access System (Zoom RDL; Imperative Care, Inc., Campbell, CA) catheters.22–25 Interestingly, a smaller A3 angle was associated with procedural complications, even though no correlation between A3 and the conversion rate was appreciated. Based on the distribution of the complications, most of the complications occur around A3, close to 50°; however, a clear cutoff is hard to interpret. The majority of complications occurred at an A3 angle of <90°.

In the TR approach, type II and type III aortic arch with bovine anatomy are associated with a higher success rate for completing the intended procedure of the left common and the internal carotid artery. 13 Interestingly, while 80% of the carotid stenting was performed via the TF approach, approximately 50% of the right carotid artery stenting was via the TR approach, and approximately 50% of the left carotid artery stenting was via the TF approach. This is quite conceivably due to the selection bias and the perceived complexity of selectively catheterizing and navigating the access guide catheter to the left common and external carotid artery with the transradial approach across the aortic arch and acute angle of the left common carotid artery from the aortic arch (A3). Perhaps keeping geometric constraints in mind, the patients were selected for the most successful approach, which impacted the potential to appreciate any significant differences between the type of approach and the arch anatomy. A randomized study to perform eCAS of the right and left carotid arteries via the TR versus TF approach is recommended to remove selection bias and to ascertain if any anatomical and geometric restrictions exist.

Limitations:

There are several limitations to this study that should be acknowledged. First, as a retrospective multi-center analysis, the findings are subject to biases such as selection bias and missing data. Although we performed a sensitivity analysis to account for patients lost to follow-up, there remains a possibility that some complications may have gone unreported, particularly in patients who did not have post-procedural follow-up beyond 30 days.

The variability in imaging modalities (CTA vs. MRA) and the quality of images across participating centers could have influenced the accuracy of anatomical measurements. Additionally, the lack of standardized protocols for measuring vessel tortuosity and aortic arch angles may have introduced inconsistencies in data collection, potentially affecting the analysis of anatomical predictors of transradial (TR) approach success. An artificial intelligence or nonlinear analysis of various combinations may be more meaningful than an individual angle.

The study is limited by its focus on eCAS procedures. These findings may not be generalizable to emergent cases or other neuroendovascular procedures, which may have different anatomical and procedural considerations. Moreover, our study primarily evaluated anatomical factors without accounting for operator experience, which could be a significant determinant of TR approach success and complications. Variations in techniques and adaptation to imaging findings among Neurointerventionalists make analysis challenging.

Lastly, while the study did not formally adjust for multiple comparisons, the exploratory nature of the study and the multiple tests performed may have inflated the risk of Type I error. In addition, there was a small number of complications, especially relative to the sample size. Further large-scale prospective studies are needed to validate these results and determine the optimal patient selection criteria for the TR approach in carotid artery stenting.

Conclusion

Transradial carotid artery stenting can be safely performed in both right and left carotid disease. The angle of the left carotid artery origin predicted an increased risk of complications, but we did not find any other aortic arch types or great vessel geometry that predicted complications. Patients who require conversion from TR to TF may be at increased risk of stroke, ICH, and MI. Further studies are needed to identify anatomic features conducive to TR versus TF approaches for neuro intervention to reduce conversion rates.

Acknowledgments

None.

Footnotes

Authors’ note: This research was supported (in whole or in part) by HCA Healthcare and/or HCA Healthcare-affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Data availability statement: Data is available upon reasonable request.

  • The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article:
  • 1. Dr. Mohamad Ezzeldin:
    • Speaker/Consultant for Viz AI., Stryker, and Imperative care. Small investment in Galaxy Therapeutics.
  • 2. Dr. Ameer Hassan:
    • Consultant/Speaker: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care, Galaxy Therapeutics, Route 92 and Perfuze.
    • Principal Investigator: COMPLETE study—Penumbra, LVO SYNCHRONISE—Viz.ai, Millipede Stroke Trial—Perfuze, RESCUE—ICAD—Medtronic.
    • Steering Committee/Publication committee member: SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, DELPHI, DISTALS
    • DSMB—COMAND trial
  • 3. Dr. M. Shazam Hussain
    • Consultant Cerenovus (SAB, CEC), Stryker (DSMB)
    • Rapid medical (CEC).
    • Core lab PI—Medtronic, Microvention.
  • 4. Dr. Peter Kan:
    • Stryker Consultant
  • 5. Dr. Ali Alaraj:
    • Consultant for Cerenovus
  • 6. Dr. Omar Tanweer:
    • Consulting Agreements: Viz.AI, Inc., Penumbra, Inc., Balt, Inc., Stryker Inc., Imperative Inc., Q’Apel Inc. Proctor: Microvention Inc., Medtronic Inc.
  • 7. Dr. Farhan Siddiq:
    • Consultant Microvention, Grants from NIH, CNS, SNIS.

Ethics approval: HCA Houston Healthcare Kingwood Institutional Review Board has determined this retrospective research activity to be exempt or excluded from Institutional Review Board (IRB) oversight in accordance with current regulations and institutional policy. Our internal reference number for this determination is 2024-1092. There was no direct patient contact in performing this study. In addition, our patients sign a data usage form at registration related to data collection and utilization of their data for research. The research was overseen in our research protocol submitted for IRB review and research committee who holds monthly ethics reviews.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

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