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Radial Artery Catheterization for Neuroendovascular Procedures

Clinical Outcomes and Patient Satisfaction Measures
Originally publishedhttps://doi.org/10.1161/STROKEAHA.119.025811Stroke. 2019;50:2587–2590

Abstract

Background and Purpose—

Radial artery catheterization is an alternate route of access that has started to gain more widespread use for neuroendovascular procedures, and there have been few studies that describe its safety and efficacy. We present our institution’s experience in performing neuroendovascular interventions via a transradial approach, with excellent clinical outcomes and patient satisfaction measures.

Methods—

We conducted a retrospective analysis and identified 223 patients who underwent 233 consecutive neuroendovascular interventions via radial artery access at our institution. The incidence of perioperative and postprocedural complications was investigated. We identified a subset of 98 patients who have undergone both transradial and transfemoral cerebral angiograms and compared clinical outcomes and patient satisfaction measures between the 2 groups.

Results—

The overall incidence of complications was low across all procedures performed via transradial access. Peri-procedurally, only 2 patients had symptomatic radial artery spasm, and there were no instances of iatrogenic complications (vessel dissection, stroke, and hemorrhage). 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. The mean procedure time was shorter for diagnostic angiograms performed via transradial versus transfemoral access (18.8±15.8 versus 39.5±31.1 minutes; P=0.025). Patients overall reported shorter recovery times with transradial access, and the majority of patients (94%) would elect to have subsequent procedures performed via this route.

Conclusions—

Radial artery catheterization 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.

Radial artery catheterization has been shown to be a safe and effective means of access for a variety of interventional procedures. Several large scale studies, particularly in the field of interventional cardiology, have shown that radial artery access is associated with fewer access site complications than the standard trans-femoral approach, with better patient satisfaction measures.1 However, radial artery catheterization has only recently started to gain more prominence in the field of neuroendovascular surgery.2,3

Femoral artery catheterization requires patients to tolerate a painful and uncomfortable procedure, with associated potential complications such as pseudoaneurysm formation, retroperitoneal hematoma, and artery occlusion.4 Compared with groin access, radial artery catheterization has been shown to confer a lower risk of local neurovascular complications and improved quality-of-life metrics.5

Herein, we present our institution’s case series of 233 consecutive neuroendovascular procedures performed via radial artery access. We also report patient satisfaction outcomes in a cohort of patients who have undergone both radial and femoral artery catheterization. We hope this study—to our knowledge, the largest case series to date—adds to the growing body of literature that continues to lend credence to the more prevalent use of radial artery access when performing neuroendovascular procedures.

Methods

Study Design

The study protocol was approved by our Institutional Review Board, and the need for informed consent was waived. The authors declare that all supporting data is present within the article. We conducted a retrospective analysis and identified 223 patients who underwent 233 consecutive neuroendovascular interventions via radial artery access at our institution. There were no set inclusion or exclusion criteria; instead, we progressively used transradial approach more often as we became more adept at the procedure. (Dr Jabbour now initially attempts to perform all diagnostic angiograms via the transradial approach.) We accessed patients’ electronic medical record and collected relevant data related to their procedure for data analysis.

We identified a cohort of patients who have undergone diagnostic cerebral angiograms via both radial and femoral artery access and administered a 5-question patient satisfaction survey conducted via telephone (Figure). The questionnaire was administered to all patients in preparation of this article, regardless of when their transradial procedure was performed. All patients had initially undergone femoral access, and presented for a subsequent angiogram that was performed via transradial access. The survey was assessed via a Likert scale of 1 to 5 (1-strongly disagree; 3-neutral; and 5-strongly agree).

Figure.

Figure. Patients were provided with 5 statements pertaining to their experience via transradial and transfemoral access, and asked to rate their opinion for each on a scale of 1 to 5 (1-strongly disagree; 3-neutral; and 5-strongly agree). The percentage breakdown of responses for each question is shown. Over half the respondents agreed or strongly agreed that transradial approach was less painful, and had a shorter recovery time, compared with femoral approach. The vast majority of patients agree or strongly agree that should they require a subsequent neuroendovascular procedure; they would prefer it was performed via a transradial approach.

Statistical Analysis

Analysis was performed using unpaired t test, χ2, Fisher’s exact tests, and ANOVA, as appropriate. Games-Howell post hoc analysis was used in the ANOVA analysis for cohorts without homogeneity of variances. Statistical analysis was performed using IBM SPSS (Version 24.0. Armonk, NY: IBM Corp).

Results

Clinical Outcomes

Our retrospective study included 233 consecutive neuroendovascular interventions performed via radial artery access (Table I in the online-only Data Supplement). Details of operative procedures and outcomes for patients who underwent treatment of cerebral aneurysms, mechanical thrombectomy, and carotid artery stent placement can be found in the online-only Data Supplement.

The vast majority of procedures were able to be successfully completed via radial artery access (93%); in 16 cases, radial access was abandoned, and femoral access was used instead. In 6 cases, initial radial artery catheterization was unsuccessful and required transfemoral access instead. There were a total of 10 cases where transradial access was achieved, but the procedure could not be completed due to technical limitations, thus prompting groin access instead. There was a low rate of intraoperative complications.

In the immediate postoperative recovery setting, 10 patients reported significant pain or discomfort, warranting further assessment. Of note, in all these instances, symptoms were able to be treated via conservative measures. Five patients had persistent symptoms at the time of their follow-up in clinic.

Cerebral Angiograms Performed Radial Versus Femoral Artery Access

We identified a subset cohort of 98 patients who have undergone diagnostic cerebral angiograms via both approaches (in all cases, these patients had initially undergone femoral access). We chose to limit our analysis to only diagnostic cerebral angiograms such that variations in procedural complexity would not confound clinical outcomes and patient satisfactions.

The mean procedure length—measured as the time between the first fluoroscopic taken while attempting access until the time the sheath was removed—for diagnostic cerebral angiograms performed via transradial approach was shorter than those completed via femoral access (18.8±15.8 versus 39.5±31.1 minutes; P=0.025). There was no difference in the rate of peri-procedural or postoperative complications between angiograms performed via radial versus femoral artery access (Table II in the online-only Data Supplement).

Patients who underwent same-day diagnostic cerebral angiograms via radial artery access had considerably shorter recovery times spent in post anesthesia care unit. The mean time patients spent in recovery before be was 127.8±39 minutes. In contrast, patients who undergo femoral access must spend a minimum of between 4 and 6 hours lying flat after their procedure before they are mobilized.

Patient Satisfaction Measures

Patients who have undergone cerebral angiograms via both femoral and, subsequently, radial artery access (N=98 eligible subjects) were asked to complete a 5-point telephone questionnaire (Figure). A total of 66 patients (67.3%) were able to be contacted and willing to complete the questionnaire; 4 patients (4.1%) were deceased at the time of follow-up, and the remaining 28 patients (28.6%) were not able to be reached.

Patients rated the transradial approach as having a shorter duration of recovery compared with a transfemoral approach, with 36.4% and 34.8% of respondents provided a rating of 4/5 (agree) and 5/5 (strongly agree), respectively. When patients were queried whether they would prefer a transradial or transfemoral approach should they need a subsequent procedure performed in the future (question 5), the vast majority of patients were strongly in favor of transradial, and only 6% of total responders had a preference towards the transfemoral approach.

Discussion

Over the past decade, transradial access has become the preferred method of access for cardiac interventionalists, and several large scale randomized, controlled studies have shown that it is a safe and effective means of performing a wide range of procedures.6 Currently, radial artery access is scarcely used for neuroendovascular procedures. This study—to our knowledge, the largest case series to date—further highlights the utility, safety, and patient outcomes comprising a wide variety of neuroendovascular procedures.

This case series includes 233 consecutive cases performed via transradial access and includes the very first such procedures performed at our institution. There was, overall, a very low incidence of minor (hematoma and paresthesia) and major complications (nerve injury, hand ischemia, and compartment syndrome) incurred via using transradial access. Radial artery spasm was only appreciated in 2 cases, both of which were able to be treated without any adverse clinical sequelae. There were no documented events of radial artery occlusion incurred. Our study shows that the mean time for cerebral angiograms performed via radial artery access was, in fact, lower than transfemoral angiograms. Taken together, the ability to perform an array of interventions with comparable operative times suggest that the learned technical prowess to perform procedures via transradial access is, in fact, readily achievable, and our trainees have become adept at performing this technique.7 At the present, we do not have a set inclusion or exclusion criteria for selecting patients for transradial access, and this is a limitation of our current study. As we continue to perform more endovascular procedures via radial approach, we hope to develop more stringent criteria for determining which patients are better suited for transradial versus transfemoral access.

The history of endovascular neurosurgery reveals that technical innovation improves clinical outcomes and patient satisfaction, with complex pathologies able to be treated via less invasive techniques with decreased postoperative recovery times and improved patient outcomes.8 In modern healthcare, there is an emphasis placed on patient-centered care.9 Our study reveals that among patients who have had angiograms performed via both transfemoral and transradial access, patients strongly prefer the latter. The transradial procedure was perceived to be less painful than transfemoral access, with associated shorter recovery times reported. When asked which route of access they would prefer for a subsequent neuroendovascular procedure, the overwhelming majority of patients (94%) preferred the transradial option; other studies have reported similar patient preferences.1,10,11

Conclusions

The results of this study illustrate that transradial access is a safe and effective means of performing a wide variety of neuroendovascular procedures, and is associated with excellent patient satisfaction measures compared with transfemoral access. Given the positive patient satisfaction outcomes reported, we have transitioned our practice to perform all our diagnostic angiograms and intraoperative angiograms, via transradial access. Further investigation will need to be pursued pertaining to long-term outcomes among larger patient cohorts, for the treatment of stroke, cerebral aneurysms, and arterio-venous malformations. We hope that the results of this study give credence to the use of transradial access for cerebral angiography among practicing and aspiring neuroendovascular interventionalists and push the envelope of what our field has to offer.

Footnotes

The online-only Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.119.025811.

Correspondence to Pascal M. Jabbour, MD, Thomas Jefferson University Hospital, Philadelphia, PA 19107. Email

References

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