Arm-only access for combined transarterial and transvenous neurointerventional procedures

Dural Arteriovenous Fistula Treated with Transvenous Embolization via the Upper Limb Cutaneous Vein

Objective

In recent years, the transradial artery approach has gained prominence and is increasingly employed in neurovascular angiography and therapy due to its safety, reduced complications, and minimal invasiveness. While various venous approaches, including the conventional transfemoral vein approach, exist for procedures such as transvenous embolization, recent reports have highlighted methods involving upper extremity cutaneous veins. However, the practicality and efficacy of these approaches remain unclear.

Case Presentations

This study presents our experience with three cases of dural arteriovenous fistulas, where transvenous embolization was performed via upper limb cutaneous veins. In all instances, the arteriovenous approach was successfully executed using a single upper extremity, leading to the successful completion of treatment.

Conclusion

This technique demonstrates significant advantages, not only in terms of its minimal invasiveness but also due to its simplicity and safety. Anticipating broader acceptance in the future, this approach offers a promising avenue for further exploration in neurovascular interventions.

Arm-only combined transarterial and transvenous access for neurointerventional procedures: a double-center retrospective study

OBJECTIVE

This study aims to share our experience with the arm-only combined transarterial and transvenous access approach for neurointerventional procedures and evaluate its efficacy and safety.

METHODS

The arm-only combined transarterial and transvenous access approach was performed using the right/bilateral proximal radial arteries and the right forearm superficial vein system, guided by ultrasonic guidance. Arterial access closure was achieved using a transradial band radial compression device, while manual compression was utilized for venous approach closure.

RESULTS

Thirteen procedures were successfully performed using the arm-only combined transarterial and transvenous access approach, yielding favorable outcomes. The procedures included dural arteriovenous fistula embolization (seven cases), cerebral arteriovenous malformation embolization (four cases), venous sinus thrombosis catheter-directed thrombolysis and intravenous thrombectomy (one case), and cerebral venous sinus stenosis manometry (one case). All procedures were uneventful, allowing patients to ambulate on the same day. At discharge, all patients exhibited modified Rankin scores of 0-2, without any access site or perioperative complications.

CONCLUSION

This double-center study preliminarily demonstrates the feasibility and safety of arm-only combined transarterial and transvenous access applied in neurointerventional procedures for complicated cerebrovascular diseases. The proximal radial artery and forearm superficial vein are recommended as the primary access sites. Unobstructed compression is strongly recommended for radial approach closure.

ADVANCES IN KNOWLEDGE

This study aimed to add evidence and experience on the arm-only combined transarterial and transvenous access, as a new approach, for neurointerventional treatment that required arteriovenous approaches.

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistula via Radial Artery and Median Cubital Vein

Cavernous sinus dural arteriovenous fistula (CS-DAVF) is an arteriovenous shunt where there is fistulous blood flow from the dural arteries from the internal or external carotid artery into the cavernous sinus. The current mainstay of therapy is endovascular treatment. We present a case of restrictive type of CS-DAVF in a 75-year-old male who presented with right eye symptoms. He was treated with embolisation using trans-radial artery access for angiographic runs and a median cubital vein access navigating into the cavernous sinus for coil deployment. This technique completely avoids the conventional technique of a femoral approach and confines all access to the arm. Therefore, there are less risks and complications associated with an arm access, improves patients' comfort and mobility post procedure. Transradial artery and cubital vein access allows for a safe and convenient alternative technique using the arm as compared with conventional transfemoral approach for treatment of CS-DAVF.

#RadialFirst and #RadialForNeuro: A descriptive analysis of Twitter conversations regarding transradial access

BACKGROUND

Transradial access for neurointerventional procedures was adopted and modified from cardiovascular intervention and is increasingly established as a safe and effective alternative to transfemoral catheterization. As social media influences public opinion on medical treatment, this study analyzes Twitter conversations to elucidate social media's depiction of transradial access as a neurointerventional tool.

MATERIALS AND METHODS

Twitter hashtags #RadialFirst and #RadialForNeuro were evaluated using a mixed-method analysis of quantitative social media metrics and qualitative thematic analysis.

RESULTS

Between January 2015 and April 2020, 104,146 tweets from 141 countries employed the hashtag #RadialFirst (2015 (1); 2016 (0); 2017 (22,804); 2018 (33,074); 2019 (38,352); 2020 (9,915 January-April)). These generated 226,909,374 impressions and were retweeted 80,120 times by 13,707 users. Media was present in 62.5% of tweets (e.g. wrist image, angiographic runs) but only 14.5% had a reference article. Physicians authored 70.8% of tweets; interventional cardiologists accounted for 83% of top 100 influencers. #RadialForNeuro is more nascent (6 posts in 2019; 323 posts January-April 2020), with 392,662 impressions, and 254 retweets by 177 users; physicians authored 35.6%. Compared to #RadialFirst, #RadialforNeuro tweets were more likely to include media (76%), less likely to include citations (9.7%), and more likely to discuss complications and troubleshooting techniques.

CONCLUSION

Twitter activity regarding transradial access permits information dissemination and discussion on approach benefits and challenges. However, many posts arise from non-physician sources and lack links to peer-reviewed publication. The public should be mindful that tweets may reflect opinions, rather than experience or scientific evidence.

Single Arm Access for Combined Transarterial and Transvenous Neurointerventional Procedures

A concurrent arterial and venous access is routinely obtained for diagnosis and treatment of various neurovascular diseases. Traditionally, venous access is obtained by accessing the femoral vein or through direct internal jugular puncture. Although complication rates are low, life-threatening severe complications have been reported. Moreover, venous access can be challenging in large body habitus patients through these traditional routes. There is a growing trend of utilizing radial artery access for neuroendovascular procedures. Nevertheless, the use of upper limb veins in neurointerventional procedures is rare. We present 3 cases of the concurrent arterial and venous approach through the radial artery and cephalic or basilic vein of the forearm for diagnostic cerebral arteriography and venography. Radial access was obtained by using the standard technique, and venous access was obtained by cannulating cephalic or basilic vein using ultrasound guidance, and a 5F or 6F short sheath was placed. Venous angiography and catheterization of right and left internal jugular veins were then performed using a Simmons (SIM) 2 catheter alone or using 6F Envoy guide catheter coaxially over the SIM 2 catheter if an additional support for microcatheter was needed. Procedures were successfully completed with no adverse effects, and patients were discharged home the same day. We also describe the technique for the reformation of the SIM 2 catheter in the venous system for catheterization of right and left internal jugular veins through the arm access.

Upper extremity transvenous access for neuroendovascular procedures: an international multicenter case series

BACKGROUND

Radial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates.

METHODS

An international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature.

RESULTS

One hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%).

CONCLUSIONS

UETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.