Anatomic Snuffbox (Distal Radial Artery) and Radial Artery Access for Treatment of Intracranial Aneurysms with FDA-Approved Flow Diverters

Practical uses of the BENCHMARK™ BMX®81 in the road less travelled: Guide catheter comparison for radial access in neurovascular intervention

BACKGROUND

Radial arterial access has gained interest for neurovascular procedures in recent years. Although there are no randomized control trials for neurointervention procedures using radial access, there is growing literature demonstrating its feasibility and favorable outcomes. Equipment technical improvements, like the recently introduced BENCHMARK™ BMX®81 System, have made radial navigation safer, with improved maneuverability and support for a variety of procedures. We present a multicenter case series highlighting our institutional radial access experience comparing the BMX®81 with alternative catheters.

METHODS

Multicenter retrospective cohort study of 80 patients who underwent neurovascular procedures through a radial approach. In half of the cases a BENCHMARK™ BMX®81 System was used. The comparison group consisted of the BENCHMARK™071 and 96, Neuron MAX®088 and BALLAST™ systems. Procedures included endovascular thrombectomy, carotid and brachiocephalic artery stenting, middle meningeal artery embolization, flow diverter stenting, vertebral artery sacrifice, aneurysm coiling, and WEB™ device deployment.

RESULTS

In our series, the BMX®81 was successful in the navigation of the anatomy to the target location in 95% of cases. No radial access or BMX®81 related complications were identified. There was no significant difference in fluoroscopy time between the BMX81 and the comparison group. Four patients in the comparison group had catheter-related complications due to vasospasm. Eighty-six percent of BMX®81 cases had satisfactory outcomes and no technical difficulties. The remainder presented technical difficulties, but none of these were considered secondary to the puncture site or support structure.

CONCLUSIONS

The BENCHMARK™ BMX®81 System is a recently developed guiding catheter which has design and size features supporting radial access for a variety of neurovascular interventions. Early multicenter experience highlights the ease of use and versatility of this new catheter as an alternative to transfemoral access as well as other catheters used for radial access.

Distal radial artery approach is safe and effective for cerebral angiography and neuroendovascular treatment: A single-center experience with ultrasonographic measurement

BACKGROUND

The transradial artery approach to cerebral angiography can reduce both patient stress following examination and the risk of major complications due to hematoma. Recently, the distal radial artery approach (DRA) has garnered attention in cardiology as a minimally invasive method. DRA is also considered applicable to neurosurgery, although concerns about procedural difficulty and complications persist. Therefore, this study aimed to evaluate the efficacy of the DRA in cerebral angiography and neuroendovascular treatment.

METHODS

We retrospectively selected 30 consecutive patients for whom the DRA was attempted for cerebral angiography at our hospital. The patients' age, sex, height, weight, and medical history information was collected and correlated with successful puncture and complications. The diameter of the distal radial artery (RA) was measured using ultrasonography.

RESULTS

The median patient age was 67 years (range, 32-87 years) and 21 (70%) were men. The median diameter of the distal RA was 2.3 mm (range, 1.7-3.2 mm). Distal RA puncture was successful in 23 patients (77%) and no complications were noted; however there was no significant correlation between successful puncture and any of the patient factors. Carotid artery stenting and preoperative tumor embolization were performed via DRA in six and three cases, respectively. Although puncture site hematoma occurred in only one case, all treatments were successful, and no major complications were observed.

CONCLUSION

DRA can be safely used for cerebral angiography and neuroendovascular treatment.

Distal versus conventional transradial access for diagnostic cerebral angiography and neurointerventional procedures: A systematic review and meta-analysis

BACKGROUND

Distal transradial artery access (dTRA) has received increasing consideration for performing diagnostic cerebral angiography and neurointerventional procedures. In this meta-analysis, we aim to evaluate the safety and efficacy of dTRA compared to conventional transradial access (cTRA) for cerebral angiography and neurointerventions.

METHOD

A systematic review and meta-analysis were conducted on studies investigating outcomes of dTRA and cTRA in neurointerventions. The primary outcome was technical success rates. Secondary outcomes included access site complication rates, crossover rates to alternative vessels, fluoroscopy time, and contrast volume. The random effects model was used to calculate the mean difference (MD) and odds ratios (OR) with 95% confidence intervals (Cl).

RESULTS

Eight retrospective observational studies with a total of 1477 patients who underwent 1175 diagnostic cerebral angiography and 516 neurointerventional procedures using 546 dTRA and 1164 cTRA approaches were included in our meta-analysis. The technical success rate was similar between dTRA and cTRA groups (95.8% vs 91.4%; OR:1.65; 95% Cl: 0.52 to 5.22; P = 0.40). Similarly, no difference was seen in dTRA and cTRA regarding access site complications (2% vs 1.4%; OR: 1.31; 95% CI: 0.47 to 3.61; P = 0.61) and access site crossover (2.1% vs 5.3%; OR: 0.55; 95% Cl: 0.28 to 1.05; P = 0.07). After resolving heterogeneity among included studies, dTRA was associated with a shorter fluoroscopy time (MD: -0.91 min; 95% CI: -1.74 to -0.09; P = 0.03) and lower contrast volume (MD: -8.32 mL; 95% CI = -14.7 to -1.94; P = 0.011).

CONCLUSION

Our findings suggest that the dTRA approach is a safe and effective alternative to the cTRA approach in patients undergoing cerebral angiography and neurointerventions.

Left Transradial Access Using a Radial-Specific Neurointerventional Guiding Sheath for Coil Embolization of Anterior Circulation Aneurysm Associated With the Aberrant Right Subclavian Artery: Technical Note and Literature Review

BACKGROUND

Aberrant right subclavian artery (ARSA) is a rare condition, but the most common anomaly of the aortic arch. Although neurointerventions via transradial access (TRA) are becoming increasingly popular worldwide, transradial carotid cannulation has been extremely challenging in patients with an ARSA. Herein, we present a case of ARSA-associated anterior communicating artery (ACoA) aneurysm that was successfully treated with a radial-specific 6F Simmons guiding sheath via left TRA. We also review the relevant literature.

METHODS

A 68-year-old-woman who was diagnosed as having an ARSA-associated ACoA aneurysm underwent simple coiling via left TRA. After the 6F Simmons guiding sheath was engaged into the right common carotid artery using the pull-back-technique, transradial quadraxial system (6F Simmons guiding sheath/6F intermediate catheter/3.2F intermediate catheter/coil-delivery microcatheter) was implemented.

RESULTS

Simple coiling of the aneurysm was successfully achieved without catheter kinking or system instability. The postprocedural course was uneventful. A follow-up magnetic resonance angiography showed no evidence of recanalization 1 years 9 months after the procedure.

CONCLUSIONS

Transradial anterior circulation intervention has been rarely used for patients with an ARSA due to unfavorable catheter trajectory. Left TRA using the 6F Simmons guiding sheath is a useful treatment option to address anterior circulation interventions for patients with an ARSA. Preoperative diagnosis of ARSA is necessary for the application of our method.

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.

Transradial Versus Transfemoral Intraoperative Cerebral Angiography for Open Cerebrovascular Surgery: Effectiveness, Safety, and Learning Curve

BACKGROUND

Intraoperative cerebral angiography (IOA) is a valuable adjunct in open and hybrid cerebrovascular surgery. Commonly, transfemoral access (TFA) is used. Lately, transradial access (TRA) has gained popularity for neurointervention. However, the TRA has not yet been compared with the TFA for IOA.

OBJECTIVE

To compare the effectiveness and safety of the TRA and TFA for IOA. In addition, the learning curve for implementing the TRA for IOA was evaluated.

METHODS

Between July 2020 and 2022, 92/1787 diagnostic cerebral angiographies met inclusion criteria for IOA. Sheath run time to primary target vessel run time (STT), amount of contrast dye (CD), fluoroscopy time (FT), and dose-area products (DAPs) were compared between TRA and TFA, different aortic arch types, and both study years.

RESULTS

One case required transitioning from TRA to TFA (1/26, 3.8%) because of a minute proximal radial vasculature. The STT, CD, FT, and DAP were similar for the TRA (n = 25) and the TFA groups (n = 67) (p = ns). One groin hematoma (1.5%) was observed in the TFA group. No other complications or any change in modified Rankin Scale were observed. Aortic arch type II/III was associated with longer STT ( P = .032) but not CD, FT, or DAP. There was a nonsignificant decline of STTs among the TRA cases ( P = .104) but stable STTs among TFA cases ( P = .775).

CONCLUSION

The TRA and TFA represent equally effective and safe routes for IOA. In addition, expertise with the TRA can rapidly be gained and facilitates tailoring the access for IOA to patient's individual anatomy and surgeon's needs.

Feasibility and Safety of Transradial Aneurysm Embolization: A Systematic Review and Meta-Analysis

OBJECTIVE

Use of the transradial access (TRA) approach for neuroendovascular procedures has been increasing in recent years. Our aim is to assess the feasibility, success rate, and complications associated with TRA for intracranial aneurysm embolization.

METHODS

PubMed, Scopus, and Embase were systematically searched for studies using TRA for intracranial aneurysm embolization. Random-effects models were used to obtain pooled rates of procedural success and complications.

RESULTS

Twenty-four studies comprising 1283 (85.9%) TRA and 122 (8.2%) distal TRA aneurysm embolization procedures were included. The pooled success rate of the 18 studies in the meta-analysis was 93.5% (95% confidence interval [CI], 91.1%-95.8%). The pooled thromboembolic complication rate was 0.5% (95% CI, 0.1%-0.9%), the hemorrhagic complication rate was 0.5% (95% CI, 0.1%-0.9%), and the access site complication rate was 0.8% (95% CI, 0.3%-1.3%). One study (4.3%) used exclusively a 7-French guide catheter, and most used a 6-French guide catheter (22 of 23 studies, 95.7%), which was further incorporated as part of a triaxial configuration through a sheathless 8-French system in 4 studies (17.4%), 7-French guide catheter in 2 studies (8.7%), and 8-French sheath in 1 study (4.3%). The embolization techniques used were flow diverter placement in 451 cases (39.1%), coiling in 376 (32.6%), stent-assisted coiling in 127 (11.0%), balloon-assisted coiling in 104 (9.0%), Woven EndoBridge system in 50 (4.3%), and flow diverter placement plus coiling in 42 (3.6%).

CONCLUSIONS

Treating intracranial aneurysms using various embolization techniques through TRA is feasible and associated with low access site and intraoperative complications.

Feasibility and Safety of Flow Diversion in the Treatment of Intracranial Aneurysms via Transradial Approach: A Single-Arm Meta Analysis

Background

While studies have confirmed that flow diversion (FD) can treat intracranial aneurysms via transradial approach (TRA), it remains unclear whether their treatment ultimately impacts safety and feasibility. We aim to conduct a systematic review and meta-analysis assessing the safety and feasibility after FD treatment of intracranial aneurysms via TRA.

Methods

PubMed, EMBASE, and Web of Science were systematically reviewed. The primary outcomes were the success rate and the access-related complications of deploying FD via TRA. Meta-analysis was performed using a random or fixed effect model based on heterogeneity. And the publication bias was evaluated using a funnel plot. This study was registered with PROSPERO, number CRD42021244448.

Results

Data from 8 studies met inclusion criteria (250 non-duplicated patients). The success rate was 93% (95% confidence interval [CI] 0.86–0.98; I² = 61.05%; p = 0.01). The access-related complications rate was 1% (95% CI 0–0.03; I² = 0.00%; p < 0.01). The mainly access-related complications included radial artery spasm (85.7%) and radial artery occlusion (14.3%). The TRA convert to transfemoral approach (TFA) was 7% (95% CI 0.02–0.14; I² = 61.05%; p = 0.01).

Conclusions

Although TFA is still the main access for FD in the treatment of intracranial aneurysms, the TRA also has a higher success rate and lower access-related complications rate. With the improvement of future experience and equipment, the TRA may become the main access for FD which has more advantages. Future studies should design prospective, multicenter randomized controlled studies for long-term follow-up.

Distal radial artery access in noncoronary procedures

Since the beginning of interventional cardiology and for decades, the femoral artery has been the access of choice for both diagnostic and interventional endovascular procedures. Due to an extensive evidence base accumulated over the last 20 years, the majority of interventional cardiologists around the world prefer classical radial artery access for both elective and emergency procedures. A similar trend has been observed for distal radial artery access over the last five years. Noncoronary endovascular surgery undergoes the same stages of improvement and optimization of access, but in a more accelerated way. The goal of this review is to analyze the literature on distal radial artery access in noncoronary procedures.

Exploring the path less traveled: Distal radial access for diagnostic and interventional neuroradiology procedures

BACKGROUND

Recently there is a trend for radial first which advocates radial artery access as the first choice to perform diagnostic and interventional neurovascular procedures. Although safer than the conventional common femoral artery access, it is associated with a high rate of radial artery occlusion. Distal radial artery access is recently proposed to avoid this complication. This study aims to assess the feasibility and safety of distal radial artery access across a wide range of interventional neurovascular procedures.

MATERIALS AND METHODS

All Interventional neurovascular cases attempted via distal radial artery access from September 2019 till March 2021 were included in the study. Data regarding patient demographics, distal radial artery diameter, access site cannulation, size of the sheath, procedural details including success rate and complications were collected.

RESULTS

During the study period, 102 patients underwent 114 procedures via the distal radial artery approach. The mean age of patients was 41.9 ± 15.2 years. Overall procedure success rate via DRA was 94.7% (108/114). 72 diagnostic cerebral angiograms and 36 interventional procedures were successfully completed while six procedures required switching to alternate access.

CONCLUSION

Distal radial artery access is a safe and feasible option for diagnostic cerebral angiography and a wide range of neurovascular procedures.