Abstract
Background
Mechanical thrombectomy (MT) is a well-established treatment for acute large-vessel occlusion. While the transfemoral approach (TFA) is the standard, it can be challenging in elderly patients with tortuous vasculature. The transbrachial approach (TBA) offers a shorter and more direct route but is associated with more puncture site complications. This study investigates the effectiveness and feasibility of TBA for right anterior circulation strokes.
Methods
A total of 23 patients who underwent MT via TBA between September 2023 and January 2025 were retrospectively analyzed and compared with 23 patients treated via TFA from March 2021 to April 2023. Patient characteristics, procedural times, recanalization rates, and complications were evaluated.
Results
The TBA group showed a shorter median puncture-to-guiding (PtoG) time (13 vs 16 min) and puncture-to-recanalization (PtoR) time (37 vs 52 min) compared to the TFA group. Successful recanalization (TICI ≥2b) was achieved in 95.7% of TBA cases versus 87.0% in TFA. One minor puncture site complication occurred in the TBA group. In rare instances, catheter kinking at the subclavian–CCA junction was observed. Sheathless technique was employed in most TBA cases to minimize puncture complications.
Conclusion
TBA is a feasible alternative for MT in right anterior circulation strokes, providing improved procedural efficiency. While associated with a higher rate of puncture complications, TBA offers a practical solution in cases where TFA or TRA may be technically challenging.
Keywords: Brachial, mechanical thrombectomy, hyperacute infarction, anterior circulation infarction, transbrachial approach
Background
Mechanical thrombectomy (MT) has been proven effective and is widely practiced worldwide. 1 Consequently, the opportunity to perform MT in elderly patients is increasing. Elderly patients often present with tortuous vessels, making it difficult to guide catheters using the traditional transfemoral approach (TFA). 2 Although the transbrachial approach (TBA) lags behind TFA and transradial approach (TRA) in terms of puncture site complications,3–6 it may offer advantages in catheter navigation, especially in time-sensitive MT cases.
This report discusses our experience and the effectiveness of TBA for MT in acute ischemic stroke limited to the right anterior circulation.
Subjects and methods
From September 2023 to January 2025, we performed MT using the TBA on 23 patients with acute ischemic stroke caused by major arterial occlusion in the right anterior circulation. We analyzed patient characteristics, endovascular procedures, postoperative outcomes, and puncture site complications. For comparison, we reviewed 23 similar cases treated with TFA between March 2021 and April 2023. All eligible cases during the study period were treated using TBA, excluding those caused by infection or neoplastic lesions.
The indication for MT was determined using non-contrast head and chest CT, and head MRI. The evaluation of aortic arch branching morphology was based on Adachi–Williams–Nakagawa classification (types A and B only). Branching from the aorta to the common carotid artery was classified using the Criado classification (types I–III). Aortic arch evaluation was based on postoperative cervical MRA. Recanalization was assessed using the Thrombolysis in Cerebral Infarction (TICI) grade, with TICI 2b or higher defined as successful.
Surgical technique
Under local anesthesia, the right brachial artery was punctured using a micropuncture set (Cook Medical, USA). Procedures were performed sheathless using 8 or 9 Fr balloon guiding catheters (BGCs) with dilator kits. A coaxial system of 8 Fr BGC/5 Fr MSK catheter/0.035 Radifocus guidewire was used. The MSK was shaped into Simmons form in the aortic arch and guided into the right common carotid artery (CCA), or directly from the subclavian to CCA. After advancing the guidewire distally into the internal carotid artery (ICA), the inner catheter and BGC were advanced.
Hemostasis post-MT was achieved with 6-h compression using Bleed Safe (Medikit, Tokyo).
Results
The TBA group (n = 23) included 15 females (65.2%) with a mean age of 81.3 years, similar to the TFA group (80.2 years). Mean NIHSS scores were 19.1 for TBA and 20.7 for TFA. Approximately half of both groups had Type III aortic arches (Table 1). The median puncture-to-guiding (PtoG) time was 13 minutes (7–22 min) for TBA and 16 minutes (7–38 min) for TFA. The median puncture-to-recanalization (PtoR) time was 37 minutes (14–73 min) for TBA and 52 minutes (23–96 min) for TFA. TBA also had fewer thrombectomy passes (1.65 vs 1.87). Successful recanalization (TICI ≥2b) was achieved in 22/23 cases (95.7%) for TBA and 20/23 (87.0%) for TFA (Table 2). No statistical significance was found due to the small sample size. Most TBA cases used 8 Fr BGCs sheathless. 6
Table 1.
Characteristic of patients.
| Characteristic | TBA group (N = 15) | TFA group (N = 15) |
|---|---|---|
| Age, mean ± SD | 81.3 ± 8.37 | 80.2 ± 9.65 |
| Female (%) | 15/23 (65.2%) | 12/23 (52.2%) |
| tPA (done) | 15/23 (65.2%) | 11/23 (47.8%) |
| NIHSS, mean ± SD | 19.1 ± 7.92 | 20.7 ± 6.68 |
| Type of aorta | ||
| Type Ⅰ | 5/23 (21.7%) | 8/23 (34.8%) |
| Type Ⅱ | 7/23 (30.4%) | 4/23 (17.3%) |
| Type Ⅲ | 11/23 (47.8%) | 11/23 (47.8%) |
| Occlusion site | ||
| ICA | 10/23 (43.5%) | 7/23 (30.4%) |
| M1 | 9/23 (39.1%) | 10/23 (43.5%) |
| M2 | 3/23 (13.0%) | 6/23 (26.1%) |
| CCA | 1/23 (4.3%) | 0/23 (0%) |
Table 2.
Device and result of patients.
| Characteristic | TBA group (N = 23) | TFA group (N = 23) |
|---|---|---|
| Median time of PtoG (min) | 13 (7–22) | 16 (7–38) |
| Median time of PtoR (min) | 37 (14–73) | 52 (23–96) |
| Guiding catheter | ||
| 8Fr OPTIMO | 12/23 (52%) | 18/23 (78.2%) |
| 9Fr OPTIMO | 0/23 (0%) | 5/23 (21.7%) |
| Branchor XS | 7/23 (30.4%) | 0/23 (0%) |
| Branchor XF | 2/23 (8.6%) | 0/23 (0%) |
| Other | 2/23 (8.6%) | 0/23 (0%) |
| Number of passes | ||
| First | 13/23 (56.5%) | 9/23 (39.1%) |
| Second | 7/23 (30.4%) | 8/23 (34.8%) |
| Three or more times | 3/23 (13.0%) | 6/23 (26.1%) |
| TICI grade | ||
| 2b> | 22/23 (95.6%) | 20/23 (87.0%) |
| 2a< | 1/23 (4.3%) | 3/23 (13.0%) |
| Puncture site complications | 1/23 (4.3%) | 0/23 (0%) |
| Catheter damage | 2/23 (8.6%) | 1/23 (4.3%) |
aPtoG (from puncture to guiding catheter placement).
bPtoR (from puncture to recanalization).
One minor puncture site complication (skin blistering due to compression) occurred in the TBA group.
A representative case
A 74-year-old male presented with occlusions at the origin of the right internal carotid artery (ICA) and the M2 segment. Diffusion-weighted imaging (DWI) showed high signal intensity in the right MCA territory. As the patient was eligible for tPA therapy, intravenous alteplase was administered, followed by MT. 1 Using a right brachial approach with an 8 Fr OPTIMO/5 Fr MSK/0.035 Radifocus guidewire combination, successful navigation to the right common carotid artery (CCA) was initially achieved. However, the OPTIMO catheter kinked at the origin of the CCA and was replaced with a Branchor XS. Angiography confirmed occlusion of the right ICA. As a result, the PtoG time was 22 minutes, the longest in this series. Percutaneous transluminal angioplasty (PTA) was performed on the ICA using a SHIDEN 4 mm × 40 mm (KANEKA MEDICS, Osaka, Japan), followed by thrombectomy on the M2 lesion using the ADAPT technique with a VECTA46 (Stryker, Michigan, USA), achieving a favorable TICI grade 2b outcome. Hemostasis was achieved with approximately 6 hours of compression using Bleed Safe, with no puncture site complications observed. Follow-up MRI on the next day showed no expansion of the infarct in the right MCA territory, and blood flow distal to the ICA remained preserved.
Discussion
MT has become standard for acute large-vessel occlusion. 1 TFA, the conventional approach, has 1.2%–5.1% failure in catheter navigation due to factors such as Type III arch and vessel tortuosity. 2 Aging populations suggest increasing difficulty in TFA navigation.
As an alternative approach, the transradial approach (TRA) is considered. 8 At our institution, endovascular procedures are primarily performed via the right radial artery. Between January 2022 and October 2024, 211 cases of anterior circulation lesions were treated with neuroendovascular therapy using the right radial approach. Of these, 106 cases involved the right anterior circulation, and none required conversion to TFA. Among the 105 cases involving the left anterior circulation, 5 cases (4.76%) required conversion to TFA. Based on these results, we consider the right arm approach effective for right anterior circulation lesions.
However, there are several challenges associated with performing MT via the radial artery. First, the use of large-bore catheters may result in insertion difficulties. The radial artery diameter has been reported to be approximately 2.2 ± 0.4 mm, 9 and inserting 8 Fr or larger guiding catheters, which are necessary for large-bore aspiration, may be difficult in some cases. Second, related to the vessel diameter, there is a time delay due to the need to administer vasodilators to prevent radial artery spasm—an extra step compared with TFA. Radial artery spasm and occlusion have been reported in 5%–30% and 1%–10% of cases, respectively.10,11 Vasodilators such as nitroglycerin and verapamil reduce radial artery spasm/occlusion and are commonly used during TRA.11,12 At our institution, a cocktail of isosorbide dinitrate and verapamil is prepared and administered in appropriate amounts before inserting the guiding catheter.
The brachial artery has a larger diameter (approx. 3.5 mm in women and 4.5 mm in men),13,14 allowing insertion of up to 9 Fr sheaths without the need for vasodilators, potentially reducing time loss. Lu et al. reported that switching from TFA to TBA prolonged treatment time by 38.5 minutes. 7 Tokunaga et al. reported a TFA BGC induction time of ∼20 minutes, 15 consistent with our TFA group’s PtoG; our TBA group showed shorter times, supporting TBA as an effective approach.3,4,7,15
Longer PtoR in TFA is likely due to less catheter stability. TBA avoids the aortic arch, providing shorter, more direct paths with better support.3,4,7
TBA has more puncture site complications compared to TFA/TRA, in part because soft tissue around the brachial artery makes compression difficult; prior work has shown higher local complication burdens with brachial access.3–5 Larger sheaths (>8 Fr) increase pseudoaneurysm risk; minimizing arteriotomy size is therefore advisable. 6 In our series, we preferentially used a sheathless technique whenever feasible to reduce puncture-site diameter, which may have contributed to the low rate of clinically significant access-site events. 6
In rare cases, as presented in the representative case, the guiding catheter may kink at the junction between the subclavian artery and the right common carotid artery (CCA) during navigation. Guiding catheters are designed with a soft distal tip and increasing proximal stiffness to enhance trackability; when a catheter must be positioned in the CCA, the soft segment can coincide with the branching point, predisposing to kinking. Additionally, pulling the guiding catheter can steepen the angle and increase mechanical stress. In this study, similar kinking events were observed in 2 of 23 cases. When kinking occurs, the lumen may collapse, necessitating catheter exchange. To prevent damage, it is advisable to advance the catheter as distally as possible to gain support from stiffer segments and to avoid retraction maneuvers after positioning (Figures 1 and 2).
Figure 1.
Representative case of mechanical thrombectomy via the transbrachial artery approach. (a) MRI, DWI shows scattered abnormal hyperintensity in the MCA territory. (b) MRA reveals an occlusion of the right ICA. (c) Occlusion confirmed at the ICA origin (arrow). (d) PTA (percutaneous transluminal angioplasty) with SHIDEN achieved dilation and recanalization of the ICA. (e) Final angiographic image shows good visualization of the ICA.
Figure 2.
MRI the day after the procedure. (a) MRI DWI shows slight enlargement of the hyperintense area in the right MCA territory compared to preoperation. (b) MRI FLAIR reveals edematous changes around the infarcted area. (c) MRA demonstrates good visualization of the right ICA, including its distal branches.
Conclusion
Although TBA has more puncture complications,3–6 it is a viable approach for MT in right anterior circulation strokes, particularly when rapid access is critical and conventional approaches are challenging.3,4,7,15
Footnotes
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author received no financial support for the research, authorship, and/or publication of this article.
Ethics considerations
The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of National Hospital Organization Yokohama Medical Center (approval # 2024-20) on January 27, 2025, with the need for written informed consent waived.
ORCID iD
Naoyuki Noda https://orcid.org/0009-0009-3049-907X
Data Availability Statement
Cite this data in your research. All data generated or analyzed during this study are included in this published article.*
References
- 1.Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet Lond Engl 2016; 387(10029): 1723. [DOI] [PubMed] [Google Scholar]
- 2.Ribo M, Flores A, Rubiera M, et al. Difficult catheter access to the occluded vessel during endovascular treatment of acute ischemic stroke is associated with worse clinical outcome. J Neurointerventional Surg 2013; 5(Suppl 1): i70–73. [DOI] [PubMed] [Google Scholar]
- 3.Okawa M, Tateshima S, Liebeskind D, et al. Successful recanalization for acute ischemic stroke via the transbrachial approach. J Neurointerventional Surg 2016; 8(2): 122–125. [DOI] [PubMed] [Google Scholar]
- 4.Lee DG, Lee DH, Shim JH, et al. Feasibility of the transradial or the transbrachial approach in various neurointerventional procedures. Neurointervention 2015; 10(2): 74–81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kiemeneij F, Laarman GJ, Odekerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the ACCESS study. J Am Coll Cardiol 1997; 29(6): 1269. [DOI] [PubMed] [Google Scholar]
- 6.Webber GW, Jang J, Gustavson S, et al. Contemporary management of postcatheterization pseudoaneurysms. Circulation 2007; 115(20): 2666. [DOI] [PubMed] [Google Scholar]
- 7.Lu CJ, Lin YH, Chu HJ, et al. Safety and efficacy of the transbrachial approach for endovascular thrombectomy in patients with acute large vessel occlusion stroke. J Formos Med Assoc 2021; 120(1 Pt 3): 705–712. [DOI] [PubMed] [Google Scholar]
- 8.Haussen DC, Nogueira RG, DeSousa KG, et al. Transradial access in acute ischemic stroke intervention. J Neurointerventional Surg 2016; 8(3): 247–250. [DOI] [PubMed] [Google Scholar]
- 9.Ashraf T, Panhwar Z, Habib S, et al. Size of radial and ulnar artery in local population. J Pakistan Med Assoc 2010; 60(10): 817–819. [PubMed] [Google Scholar]
- 10.Hahalis G, Aznaouridis K, Tsigkas G, et al. Radial artery and ulnar artery occlusions following coronary procedures and the impact of anticoagulation: ARTEMIS (Radial and Ulnar ARTEry Occlusion Meta-AnalysIS) systematic review and meta-analysis. J Am Heart Assoc 2017; 6(8): e005430. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Avdikos G, Karatasakis A, Tsoumeleas A, et al. Radial artery occlusion after transradial coronary catheterization. Cardiovasc Diagn Ther 2017; 7(3): 305–316. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Chen CW, Lin CL, Lin TK, et al. A simple and effective regimen for prevention of radial artery spasm during coronary catheterization. Cardiology 2006; 105(1): 43–47. [DOI] [PubMed] [Google Scholar]
- 13.Dalli E, Segarra L, Ruvira J, et al. [Brachial artery flow-mediated dilation in healthy men, men with risk factors, and men with acute myocardial infarction. Importance of occlusion-cuff position]. Rev Esp Cardiol 2002; 55(9): 928. [DOI] [PubMed] [Google Scholar]
- 14.Holubkov R, Karas RH, Pepine CJ, et al. Large brachial artery diameter is associated with angiographic coronary artery disease in women. Am Heart J 2002; 143(5): 802. [DOI] [PubMed] [Google Scholar]
- 15.Tokunaga S, Tsurusaki Y, Sambongi Y, et al. Balloon-inflation anchoring technique for insertion of a guiding catheter in acute mechanical thrombectomy. J Neuroendovasc Ther 2017; 11: 53–58. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Cite this data in your research. All data generated or analyzed during this study are included in this published article.*