The best outcomes were seen in patients with unfavorable arches—the authors say this deserves further exploration.
Carotid artery stenting via radial access can be accomplished with a high procedural success rate and low risks of mortality, access-site complications, and cerebrovascular complications, according to a meta-analysis published online June 14, 2019, ahead of print in the Journal of NeuroInterventional Surgery.
“A lot of neurointerventionalists are hesitant to do interventions by radial access at the moment, particularly because they are worried about being able to get into the common carotid artery from the radial access,” co-author Kartik Dev Bhatia, MD (Toronto Western Hospital, Canada) told Neurovascular Exchange in an interview. “There have been real concerns about how to get around the tortuosity when you go from the radial access to get to the common carotid artery,” he continued. “But as we get newer and better catheters that are able to do this, I think that it is less and less of a concern. We are now fairly reliably able to get a guide into most arteries from the right radial access.”
Operators often hesitate to move away from the techniques that they used during training and have developed a high level of comfort and expertise with, he added, but “the advantages in terms of access-point complications are very significant, especially in patients on dual antiplatelets.”
The meta-analysis, led by Tanaporn Jaroenngarmsamer, MD, (Ramathibodi Hospital, Mahidol University, Bangkok, Thailand), pooled data from four retrospective and three prospective studies published between 2007 and 2018. In all, there were 723 patients who underwent carotid artery stenting via radial artery access. The three most recent studies were two-arm trials comparing the radial and femoral approaches.
The meta-analysis was limited by statistically significant heterogeneity for the primary outcome of procedural success. The seven eligible studies reported a pooled procedural success rate of 90.8%.
Asymptomatic radial artery occlusion occurred in 5.9% and forearm hematoma in 1.4% of patients. The risk of minor stroke/TIA was 1.9% (95% CI 0.6%-3.8%; I2 = 42.3%) and major stroke was 1.0% (95% CI 0.4%-1.8%; I2 = 0%). There were three deaths across the seven studies, resulting in a cumulative mortality rate of 0.6% (95% CI 0.2%-1.3%; I2 = 0%).
“Interventional cardiologists are able to achieve a 90% success rate through radial access for carotid artery stenting, so we should be able to at least match that as neurointerventionalists,” said Bhatia. “In addition, the access-site complication rate was very, very low at 0.4%, definitely lower than anyone can achieve with femoral access [in patients] who have dual antiplatelets onboard.”
Choose the Best Approach for Each Patient
Bhatia pointed out that the studies with the highest success rates included patients with the most difficult arches, such as type III or bovine.
“As a result, radial stenting shouldn’t really replace the femoral approach, but rather it is very useful in those patients who are the hardest to [access] from the femoral approach,” he recommended. “Radial access is probably not good for all cases. I think it should be used in conjunction or as an alternative to femoral access for difficult arches. In particular, the lowest success rate [using the radial approach] was in patients with a nonbovine arch of conventional origin of the left common carotid artery, and they are relatively easy to do by femoral access.”
The next step, said Bhatia, is to conduct a randomized clinical trial comparing femoral with radial access in patients with unfavorable arches.
Jaroenngarmsamer T, Bhatia KD, Kortman H, et al. . J NeuroIntervent Surg. 2019;Epub ahead of print.
Bhatia and Jaroenngarmsamer report no relevant conflicts of interest.