In the largest cohort study to date, new research from Jefferson (Philadelphia University and Thomas Jefferson University, Philadelphia, USA) demonstrates that transradial surgery, done via the wrist, is safe and effective for a broad range of neuroendovascular procedures, and gives patients faster recovery with less procedural risk. Neurointerventionists most commonly use a transfemoral approach, threading instruments through arteries in the groin.
“Despite improved safety shown in large cardiology trials, transradial brain surgeries via the wrist are much less common”, says senior author of the study and neurosurgeon Pascal Jabbour (Jefferson, Philadelphia, USA). “Neurosurgeons tend to prefer the transfemoral approach on which many of us were trained. But our research demonstrates that all kinds of neurological procedures can be done effectively and even more safely via the wrist.”
Transradial access has been widely adopted by interventional radiologists across a range of procedures, with many advocating for its use due to its positive clinical outcomes and patient satisfaction measures.
Jabbour and his team, including first author Omaditya Khanna, retrospectively examined the medical records of 223 patients who underwent 233 consecutive neuroendovascular interventions via radial artery access at Jefferson. The procedures included diagnostic angiograms, mechanical thrombectomies, arteriovenous malformation (AVM)/ arteriovenous fistulae (AVF) embolizations, coiling, stent-assisted-coiling, Woven EndoBridge (WEB) intracranial aneurysm device placement and flow-diversion treatments of cerebral aneurysms, and carotid stent placement.
A subset of 66 patients who had undergone both transfemoral and transradial surgeries were selected to complete a satisfaction survey to assess their preference. As published in Stroke, the majority of patients—94%—said they preferred surgery through the transradial route.
In addition, patients overall reported shorter recovery times with transradial access. It is easier to ensure a blood vessel in the wrist has clotted, and so patients can go home shortly after surgery, rather than laying horizontally for four to six hours after transfemoral surgery. The mean procedure time was also shorter for diagnostic angiograms performed via transradial versus transfemoral access (18.8±15.8 versus 39.5±31.1 minutes; p=0.025).
“Lying flat after certain kinds of brain surgery should be avoided in cases with high intracranial pressure, and yet it is the best way to prevent groin and internal bleeds,” comments Jabbour. “For these cases surgery via the wrist is by far the safest option.”
One of the most compelling reasons to change practice, says Jabbour, is that it eliminates the risk of rare but potentially dangerous complications of post-surgical bleeds in the groin and retroperitoneal area, which can be difficult to detect. The overall incidence of perioperative and postprocedural complications was investigated, and was found to be low across all procedures performed via transradial access. Periprocedurally, only two patients had symptomatic radial artery spasm, and there were no instances of iatrogenic complications (such as vessel dissection, stroke, and haemorrhage).
In 10 cases (4.3%), the intended procedure could not be completed via a transradial approach, and, thus, femoral artery access had to be pursued instead. Ten patients complained of minor postprocedural complications, although none required therapeutic intervention.
Jabbour and colleagues conclude: “Radial artery catheterisation is a safe and durable alternative to perform a wide range of neuroendovascular procedures, with a low rate of complications. On the whole, patients prefer transradial compared with transfemoral access.”
Transradial access in acute ischaemic stroke intervention
Jabbour was one of the first neurosurgeons to perform brain surgery via the wrist and has continued to teach others this technique.
In 2016, Diogo Haussen (Emory University School of Medicine and Grady Memorial Hospital Marcus Stroke and Neuroscience Center, Atlanta, USA) and colleagues set out to describe the feasibility and safety of transradial access in the interventional management of acute ischaemic stroke. Publishing their findings in the British Medical Journal (BMJ), they concluded that failure of transfemoral access in the endovascular treatment of acute ischaemic stroke is uncommon, “but leads to unacceptable delays in reperfusion and poor outcomes. Standardisation of benchmarks for access switch could serve as a guide for neurointerventionalists. Transradial access is a valid approach for the endovascular treatment of acute ischaemic stroke.” neuroendovascular