Feasibility and safety of transradial access for pediatric neurointerventions

Therapeutic efficacy and complications of radial versus femoral access in endovascular treatment of unruptured intracranial aneurysms

PURPOSE

The transradial approach (TRA) in neuroendovascular treatment is known to have a lower risk of complications than the transfemoral approach (TFA). However, little research has focused on assessments of efficacy and risk of complications in the treatment of intracranial aneurysms. This study aimed to compare the efficacy and complications of TRA and TFA in coil embolization of unruptured intracranial aneurysms (UIAs) at our institution.

METHODS

Consecutive patients who underwent endovascular surgery via TRA or TFA at a single institution from 1 April 2019, to 28 February 2022, were retrospectively analyzed. Patients were classified into TRA and TFA groups and assessed using propensity-adjusted analysis for outcomes including fluoroscopy time, volume embolization ratio (VER), and complications.

RESULTS

A total of 163 consecutive UIAs were treated with coil embolization during the 35-months study period. The incidence of minor access site complications (ASCs) was significantly higher with TFA (20%, 25/126) than with TRA (2.7%, 1/37; p = 0.01). Propensity-adjusted analysis (matched for age, sex, aneurysm volume, embolization technique, and sheath size) revealed that TRA was associated with a lower risk of minor ASCs (odds ratio, 0.085; 95% confidence interval 0.0094-0.78; p = 0.029). However, TRA did not differ significantly from TFA with respect to fluoroscopy time, VER, major ASCs, and non-ASCs.

CONCLUSIONS

Coil embolization for UIAs via TRA can reduce risk of minor ASCs without increasing the risk of non-ASCs compared with conventional TFA, and can achieve comparable results in term of efficacy and fluoroscopy time.

Risk factors for radial artery occlusion after neurointervention for unruptured intracranial aneurysm via transradial access

PURPOSE

Neurointervention via transradial access (TRA) is less invasive than via transfemoral access. However, radial artery occlusion (RAO) may occur with TRA. The purpose of this study was to explore risk factors for RAO after coil embolization of unruptured intracranial aneurysms (UIAs) via TRA.

METHODS

Forty-two consecutive patients who underwent coil embolization for UIAs via TRA between March 2021 and March 2022 and were available for angiographic evaluation 1 year after treatment were retrospectively reviewed. Multivariate logistic regression analysis was conducted to identify potential risk factors for RAO.

RESULTS

Seventeen (40%) of the 42 patients showed RAO. Compared with the non-RAO group, radial artery size was significantly smaller (2.2 mm [interquartile range (IQR): 2.1, 2.4 mm] vs 2.6 mm [IQR: 2.5, 2.7 mm]; p = 0.001) and the incidence of radial artery spasm (RAS) was significantly higher in the RAO group. Multivariate analysis identified radial artery size (odds ratio [OR] 4.9 × 10^-3, 95% confidence interval [CI] 6.4 × 10^-5-0.38) and incidence of RAS (OR 14.8, 95%CI 2.1-105) as significant independent predictors of subsequent RAO. Based on receiver operating characteristic (ROC) curve analysis, the optimal cutoff for radial artery size was 2.5 mm (sensitivity, 82.4%; specificity, 76.0%; area under the ROC curve, 0.80 [95%CI 0.66-0.95]).

CONCLUSION

Radial artery size and RAS represent reliable parameters for predicting RAO 1 year after coil embolization for UIA via TRA. Prophylaxis against RAS and limiting neurointervention via TRA to patients with radial artery larger than 2.5 mm in diameter may reduce the risk of postoperative RAO.

Four French sheath-based transradial cerebral angiographies in the elderly: A single neurointerventionalist's experience

BACKGROUND

Catheter angiography via transradial access (TRA) is better at reducing access site complications and morbidity than via transfemoral access (TFA). The rate of periprocedural complications increases in elderly populations and using a smaller sheath can help reduce access site complications. The aim of this study was to assess the feasibility and safety of 4 F sheath-based TRA cerebral angiography in elderly patients (≥65 years) and compare it to TFA cerebral angiography.

METHODS

The medical records of elderly patients undergoing diagnostic cerebral angiography with a single neurointerventionalist via TRA (57 cases, from July 2019 to December 2020) versus TFA (69 cases, from January 2018 to June 2019) were retrospectively reviewed. All TRA angiographies were performed via right radial artery access with a 4 F sheath and a 4 F Simmons 2 catheter.

RESULTS

There were no significant differences (TRA vs. TFA) in age (71.1 ± 4.0 vs. 72.1 ± 4.6 years, p = 0.189), accessed vessels (3.9 ± 0.5 vs. 3.9 ± 0.6, p = 0.852), fluoroscopy time (7.1 ± 3.3 vs. 7.6 ± 3.5 min, p = 0.068), and radiation exposure (42.1 ± 15.8 vs. 47.0 ± 13.7 Gy-cm2, p = 0.067). However, the procedure duration was significantly shorter in the TRA group (17.2 ± 3.9 vs. 19.0 ± 6.0 min, p = 0.003). Painful groin hematoma occurred in 2 of the 69 cases (2.9%) in the TFA group. In the TRA group, access site complications were not occurred; however, catheter kinks occurred in 2 of 57 cases (3.5%).

CONCLUSIONS

The 4 F sheath-based TRA is a feasible option for diagnostic cerebral angiography in elderly patients. However, care should be taken during catheter manipulation.

Head and neck angiography in the pediatric population: single-center experience with indications, safety, feasibility, and technical differences among infants, childhood, and adolescents

OBJECTIVE

Pediatric patients are candidates for head and neck endovascular procedures less frequently than adults. Data on utilization, feasibility, safety, and technical details of head and neck angiography in the pediatric population are scarce.

METHODS

The authors performed a retrospective review of their center's endovascular database to identify all patients ≤ 18 years of age who underwent diagnostic or interventional catheter-based angiography of the head and neck. Procedure-related variables for identified patients were compared across infancy (birth to 2 years), childhood (> 2-11 years), and adolescence (> 11-18 years).

RESULTS

One hundred twenty-one pediatric patients who underwent 274 angiogram procedures were included in this study. Of these angiograms, 197 were diagnostic and 118 were interventional (including 41 of the diagnostic angiogram procedures that were performed concurrently with the intervention). The most common indications for diagnostic angiograms were suspected vascular malformations in 52 cases (26.4%) and aneurysms in 23 (11.7%). The rate of positive findings on diagnostic angiograms ranged from 27.3% to 80% according to the indication. Access site-related complications were observed after 2 punctures (0.7%). Procedure-related complications occurred in 3 patients (1.1%). In adolescents, the rates of general anesthesia use and sheathless access were significantly lower (each p < 0.001), and the rates of radial artery access (p < 0.001); 5-French (5F) (p = 0.01), 6F (p < 0.001), and 8F (p = 0.03) access; and closure device usage (p < 0.001) were significantly higher. In infants, the rates of ultrasound guidance, 4F access, and failure of the primary puncture site were significantly higher (each p < 0.001).

CONCLUSIONS

Head and neck angiograms in the pediatric population were feasible and safe in the authors' overall experience. Technical differences were observed across the infant, childhood, and adolescent groups, but safe outcomes were similar throughout these age ranges.

Transradial Cerebral Angiography: Is it Feasible and Safe for Children?

PURPOSE

To investigate the feasibility and safety of transradial cerebral angiography (TRCA) in comparison to transfemoral cerebral angiography (TFCA) in the pediatric population.

MATERIALS AND METHODS

We retrospectively reviewed pediatric patients who underwent TRCA between January 2019 and July 2020. Patients with TFCA experience were examined. Pre- and post-procedural Doppler ultrasonography was performed to evaluate TRCA complications. To evaluate differences in radiation exposure between TRCA and TFCA, we investigated the radiation dose, dose area product (DAP), fluoroscopy time, and examination time.

RESULTS

Thirty-five patients (mean age, 13.8 years; 22 male) underwent TRCA, with 18 (mean age, 13.0 years; 10 male) experiencing TFCA. TRCA was successful in all cases without technical failure. Radiation exposure including radiation dose and DAP were significantly higher in the TRCA group (474.1 mGy and 8299.6 μGy m²) compared with the TFCA group (347.8 mGy and 6342.0 μGy m²). Fluoroscopy time and total examination time were significantly longer (145.1% and 32.6%) in TRCA (15.2 and 38.6 min) group compared with the TFCA group (6.2 and 29.1 min). Among the 26 patients who underwent post-procedural Doppler ultrasonography, five (19.2%) had complications after TRCA. Two (7.7%) patients showed radial artery stenosis, two (7.7%) had hematoma at the puncture site, and one (3.8%) showed thrombotic occlusion.

CONCLUSION

Although TRCA is a technically feasible and safe method in pediatric patients, high radiation exposure to TFCA must be considered. Therefore, it should be considered as an alternative method in those with unfavorable clinical situations for performing TFCA.

LEVEL OF EVIDENCE

Level 4, Case Series.

Safety of pediatric cerebral angiography

OBJECTIVE

Catheter-based cerebral angiography is commonly used for neurovascular diagnosis in children. In this work, the authors aimed to quantify the complication rate of cerebral angiography in children, characterize these complications, and identify risk factors for complications.

METHODS

Relevant clinical data were retrospectively obtained for 587 consecutive cerebral angiography procedures performed in 390 children from March 2002 to March 2020. Complications were categorized as neurological or nonneurological, and severity was graded using a standard schema. Incidences of complications were reported as point estimates. Associations between risk factors and complications were characterized in univariate analysis using the two-tailed Fisher exact test and in multivariate analysis using multiple logistic regression with bidirectional elimination based on the Akaike information criterion. In both univariate and multivariate analyses, statistical significance was corrected for multiple comparisons using the Benjamini-Hochberg method.

RESULTS

Complications occurred in 6.5% of procedures, including neurological complications in 1.9% and nonneurological complications in 4.8%. Permanent deficits occurred in only 0.2% of cases. Overall, 0.5% of procedures resulted in major complications, while 6.0% resulted in minor complications. Female sex and a history of hypertension or ischemic stroke were associated with an increased risk of complications, while femoral artery access was associated with a decreased risk of complications.

CONCLUSIONS

Pediatric cerebral angiography was shown to have a low rate of major or permanent complications. Children who were female and those with a history of hypertension or ischemic stroke were shown to be at higher risk of complications, while the use of femoral access carried a lower risk of complications.

Reperfusion Therapies for Children With Arterial Ischemic Stroke

ABSTRACT

Modern hyperacute reperfusion therapies including intravenous thrombolysis and mechanical thrombectomy have transformed the management of arterial ischemic stroke (AIS) in adults. Multiple randomized clinical trials have demonstrated that these therapies enable remarkable improvements in clinical outcome for properly selected patients with AIS. Because pediatric patients were excluded from predicate clinical trials, there is a conspicuous lack of data to guide selection of therapies and inform age-adjusted and pathology-oriented treatment modifications for children. Specifically, technical guidance concerning treatment eligibility, drug dosing, and device implementation is lacking. This review aims to outline important features that differentiate pediatric AIS from adult AIS and provide practical strategies that will assist the stroke specialist with therapeutic decision making.

Transradial access for pediatric teenage neurointervention: A single-center case series

Transradial access is widely used in cardiological adult interventions and less in pediatrics. In recent years, this access has become more popular in the neuroradiological community in adult patients since it has fewer complications and is more comfortable for the patient after the procedure. We present a single-center case series of 52 transradial access neurointerventions (43 angiographies and 9 therapeutic procedures) in pediatric patients, with a failure of 4 cases (7.7%) in which we could not puncture the artery, crossing over to transfemoral access. Since in five cases we did angiography followed by therapeutic intervention, thus doing only one puncture access for both procedures, then our access failure rate was 10.6%. The 34 successful transradial access solely angiographies had a median radiation exposure of 887 mGy (interquartile range 628-1352), median fluoroscopy time of 9.5 min (interquartile range 7.5-15.3), and median procedure time of 28 min (interquartile range 24-33 min) Therapeutic procedure diagnosis were: one ruptured saccular aneurysm, two juvenile nasopharyngeal angiofibromas, and five arteriovenous malformations. The transradial access neurointerventions for pediatric population older than 11 years is safe and feasible, having previous experience in adults. Younger population should be considered on a case-to-case basis, depending on ultrasound measurement of the arterial diameter and the materials available.

Transradial Neuroendovascular Procedures in Adolescents: Initial Single-Center Experience

BACKGROUND AND PURPOSE

The feasibility and safety of transradial angiography is not established outside the adult literature. The objective of this study was to assess the feasibility and safety of transradial access for neuroangiography in adolescents.

MATERIALS AND METHODS

A retrospective case-control study was performed, comparing transradial neuroendovascular procedures in adolescents (age range, 10-18 years) with an age- and procedure-matched cohort of transfemoral neuroendovascular procedures. Clinical and procedural details, including type of procedure, conversion rate, fluoroscopy time, radiation dose, complications, and readmissions, were reported by descriptive statistics or measures of central tendency and compared using a t test or nonparametric equivalent. A P value < .05 was considered statistically significant.

RESULTS

Twenty adolescents (mean age, 14.6 [SD, 1.7] years, M/F ratio = 9:11) who underwent transradial neuroangiography were compared against 20 adolescents (mean age, 14.4 [SD, 2.1 ] years, M/F ratio = 12:8) who underwent transfemoral neuroangiography. We found no significant difference in procedural success (0% conversion rate), fluoroscopy times (33.7 [SD, 40.2] minutes versus 23.3 [SD, 26.2] minutes, P = .34) and radiation dose (150.9 [SD, 133.7] Gy×cm² and 122.9 [SD, 79.7] Gy×cm,² P = .43) There were 2 self-limiting postprocedural complications in the transradial group. There were no major hemorrhages, need for further interventions, or readmissions in either group.

CONCLUSIONS

The benefits of transradial angiography described for adults can likely be safely extended to adolescents. These are important data before transitioning to smaller children and should be prospectively evaluated in a larger cohort.

Distal Access Catheters for Coaxial Radial Access for Posterior Circulation Interventions

BACKGROUND

The neurointerventional field is moving towards transradial access (TRA). Among the favorable indications for TRA is for posterior circulation/vertebrobasilar interventions. For some neurointerventions, a triaxial system (guide catheter, distal access catheter [DAC], and microcatheter) is typically used for optimal support. We describe application of a new technique in which we forgo use of the guide catheter, using the DAC only for coaxial access via the radial approach and its potential advantages.

METHODS

A retrospective review was performed of our institutional database for cases using our coaxial distal access catheter technique for posterior circulation interventions. Patient characteristics and radiographic and clinical information were reviewed. All reviews were approved by institutional review board and ethics committee, and all patient identifiers were removed.

RESULTS

A total of 12 patients were found that met our criteria. Successful access and procedural completion was achieved in 11 of 12 (92%). Mechanical thrombectomy accounted for 7 cases; 2 of these patients were also stented via the same approach/technique. Other cases included 2 successful aneurysm treatments (1 flow diverter, 1 coil embolization), a balloon test occlusion for a cervical chordoma, and an arteriovenous malformation embolization.

CONCLUSIONS

TRA with a distal access catheter provides support equivalent to a triaxial system with a coaxial construct in the posterior circulation. This has the advantage of using a smaller system in the radial and vertebrobasilar artery without losing stability. This technique can be used effectively and safely for a variety of posterior circulation neuroendovascular interventions.

Forming the Simmons Catheter for Cerebral Angiography and Neurointerventions via the Transradial Approach-Techniques and Operative Videos

OBJECTIVE

Transradial access has been used increasingly for diagnostic cerebral angiography and neurointerventions. This requires development of a new skillset. Forming the Simmons catheter to catheterize the cerebral vessels is the most fundamental. Patient anatomy can complicate the formation of the Simmons catheter and the success of the procedure. The aim of this paper is to identify and describe the techniques that can be used transradially to facilitate the formation of the Simmons catheter for catheterization of the cerebral vessels.

METHODS

We reviewed our series of 85 cerebral angiograms performed via a transradial approach at our institution between 2018 and 2019. We identified the techniques employed to form the Simmons catheter and compiled operative videos demonstrating each technique and its nuances.

RESULTS

We have identified 7 techniques used to form the Simmons catheter from a right radial approach: in the ascending aorta, in the descending aorta, in the aortic arch, by deflecting the catheter off of the aortic valve with the glidewire in the common carotid artery, by deflecting the catheter off of the aortic valve with the glidewire in the descending aorta, and directly in the right or left common carotid arteries. We have identified that formation of the Simmons catheter from a left radial approach is most easily done in the descending aorta.

CONCLUSIONS

Transradial artery access has become increasingly common in cerebral angiography and neurointerventions. We describe techniques used for the formation of the Simmons catheter, a fundamental skill necessary for transradial cerebral angiogram or neurointervention.

Transradial approach for pediatric interventions: A review and analysis of the literature

BACKGROUND

Transradial access for interventions has been well studied in the adult population, but there is a paucity of literature of its use in the pediatric population.

METHODS

We conducted a systematic literature review and gathered and synthesized all of the available data into a cohesive resource for review and analysis of the topic.

RESULTS

Pooled analysis of the available data shows that transradial access in pediatric patients has a success rate of 91%, a vasospasm rate of 11.4%, and loss of pulse rate of 3.0% for a total complication rate of 14%. No permanent complications, or complications requiring surgery, were observed in any study. After stratifying for indication of intervention, neurological indications were associated with a lower complication rate compared to cardiac indications (0.1 vs 0.43, respectively, p = 0.004). In addition, studies published after 2013 were associated with a lower complication rate compared to those published during or before 2013 (0.11 vs 0.33, respectively, p = 0.01).

CONCLUSION

Compared to prior studies on pediatric transfemoral access, transradial access has a higher complication rate. But there may be a lower rate of complications that require surgical intervention. Further studies are needed to clarify any advantages that transradial access may have over transfemoral access for pediatric patients.