Abstract

Background: For cardiovascular procedures, the transradial approach has been documented to yield fewer complications than the femoral approach. It has become the approach of choice for diagnostic and therapeutic interventions involving the coronary arteries. However, few published data exist on using this approach for neuroendovascular procedures and we describe a series of ruptured cerebral aneurysms diagnosed and treated using the transradial approach.

Methods: All patients scheduled for cerebral angiography to diagnose and treat subarachnoid hemorrhages at our hospital from June 2016 to May 2018, by right radial artery access, were recruited and followed prospectively. The main outcomes of interest were the length of the procedure (in minutes), the success of treatment, and the incidence of postprocedural complications.

Results: Over the observation period, 59 patients (66% women, mean age = 48 years) with a combined 61 aneurysms treated were identified who met inclusion criteria. Of the 61 aneurysms treated, eight (13%) were within the posterior circulation (13%) and 53 (87%) the anterior circulation. Average procedural duration was 64.9 min. No occlusion or spasm of the radial artery was observed during any procedure. All patients had immediate pre- and post-embolization angiography, which revealed the guide catheter coming from the right subclavian artery. A radial pulse was evident after all interventions. All procedures were considered successful at treating the ruptured aneurysm, and no patient experienced a clinically significant complication related to the approach.

Conclusions: The transradial approach is a viable option for the diagnosis and endovascular treatment of acute cerebral aneurysms in different locations.

Keywords: Aneurysms, endovascular, subarachnoid hemorrhage, transradial approach

BACKGROUND

Endovascular coiling is considered a Class 1 Level B recommendation for ruptured cerebral aneurysms when the procedure is performed at experienced health centers.[ 6 ] The vascular access approach used at most institutions, for both diagnostic and therapeutic neuroendovascular procedures, involves puncturing the femoral artery, probably due to familiarity with this pathway. When the femoral approach is adopted, however, manual compression of the groin is required for 10–20 min once the procedure is completed, followed by application of a compression bandage and absolute rest for 4 h, then relative rest for 24 h, maintaining the bandage in position throughout this period.

Complications associated with the femoral approach, whether used diagnostically or therapeutically and despite taking all the above-mentioned precautions, include hematomas at the puncture site (1.3%), retroperitoneal hematomas (0.4%), pseudoaneurysms (0.1%), and arterial dissections (0.3%), with higher incidences of these in anticoagulated and anti-aggregated patients. Low back pain, arteriovenous fistulae at the puncture site, femoral nerve injury, chronic ischemia of the lower limb, and thromboemboli are other complications that have been described.[ 2 , 8 , 21 , 28 ] The presence of stenosis, whether due to atherosclerosis or aneurysms at the level of either the iliac arteries or abdominal aorta, often renders catheterization difficult through this approach.[ 8 , 21 , 28 ]

The radial approach for coronary angiography was initially described in 1989.[ 5 ] Since then, multiple advantages of this approach have been documented, relative to the femoral approach, which has led to the former’s habitual use at most of the centers specializing in cardiovascular hemodynamics worldwide.[ 1 , 14 , 17 , 23 , 24 ] In one prospective study comparing coronary catheterization procedures using the femoral versus radial approach for diagnosis and treatment, a higher incidence of vascular complications was identified with the former.[ 1 ] In another cardiac catheterization study comparing femoral and radial access, the incidence of pseudoaneurysms was 1.4% with the former and just 0.08% with the latter (P < 0.0001), and this difference persisted whether the procedure was diagnostic or therapeutic.[ 9 ]

In addition to its use for coronary procedures, there have been published series describing diagnostic transradial cerebral angiographies,[ 3 , 12 , 15 , 18 , 20 , 22 , 26 , 27 ] as well as isolated cases of aneurysms treated by radial embolization when femoral access was deemed impossible.[ 19 , 29 ] The current authors have already published a report describing a series of embolization procedures for different cerebral aneurysms employing coils and flow diverter devices, starting with transradial access.[ 13 ] Over the past 2 years, the right transradial approach has been our first option for the diagnosis and treatment of cerebral aneurysms in patients with a subarachnoid hemorrhage. In the present paper, we describe a group of patients with nontraumatic subarachnoid hemorrhages, and all were diagnosed and treated by radial access, detailing the technique used and complications observed in each case.

METHODS

At our institution, between June 1, 2016, and May 31, 2018, a radial access was employed for 61 aneurysms that were evaluated and treated in 59 patients with subarachnoid hemorrhage. All patients with incidental aneurysms, aneurysms already diagnosed by previous studies, and fusiform aneurysms ineligible for endovascular coiling were excluded from this series. Patient information was extracted from the hospital’s medical record database. All the procedures were performed by either one or both of the current authors, jointly, at Hospital El Cruce in Buenos Aires, Argentina.

All patients with right radial pulse palpable underwent right radial arteriopuncture.[ 4 , 13 , 25 , 30 , 31 ] The technique we used is described in a previous publication, consisting of puncture of the right radial artery between 2 cm and 4 cm proximal to the wrist. A radial approach set (Merit Medical Systems, Utah, USA) was used, and a 6-French sheath was placed using a modified Seldinger technique. Once the sheath was in position, 5cc of nitroglycerin (200 μg/mL) was administered, followed by 70 IU/kg of heparin.

All diagnostic studies to assess the supra-aortic vessels were performed with a Simmons Type II catheter (Merit Medical Systems, Utah, USA) on a 0.035-inch-thick hydrophilic guidewire.

After the diagnostic study, a 260 cm-long hydrophilic guidewire was passed either through the external carotid artery on the side corresponding to the aneurysm or through the left vertebral artery [ Figure 1 ]. For aneurysms that had to be accessed through the right vertebral artery, the vessel was entered directly with the guide catheter. The guide catheters used were the Fargo Max 6Fr (Balt Extrusion, Montmorency, France) and Guider Softip XF 6F (Stryker, Neurovascular Fremont, CA, USA). As the main vessel was approached by the guide catheter, a microcatheter was introduced under a 0.014-inch microguide, up to the aneurysm fundus, where coiling was performed, using either Headway 17 catheter (MicroVention, Inc., Tustin, CA, USA), Excelsior SL-10 catheter (Stryker, Neurovascular Fremont, CA, USA), or Vasco 10 catheter (Balt Extrusion, Montmorency, France). The coils we used were GDC or Target (Stryker, Neurovascular Fremont, CA, USA).

Figure 1

Converting from the diagnostic to the guide catheter. (a) Simmons catheter inside the left vertebral artery. (b) A 260-cm-long hydrophilic guide wire inside the left vertebral artery. (c) Guide catheter located inside the left vertebral artery.

Once coiling was completed, the microcatheter was removed and angiographic acquisition was performed to demonstrate the guide catheter’s trajectory from the right subclavian artery to the cervical vessel. Next, the guide catheter and sheath were removed, following irrigation, through the lateral route, with 5 cc of nitroglycerin (200 µg/mL). Heparin was not reversed, and a direct compression was left over the puncture site after study completion for 1 h.[ 11 , 31 ]

Table 1 lists the 59 patients treated, providing each patient’s gender and age, the general location of the aneurysm, and the duration of the procedure, in min. Note that signed, informed consent was obtained before enrolling each patient in the study, provided either by the patient or by a legally-responsible family member or guardian when a patient was unable to do so.

Table 1

SAH patients treated with endovascular coiling through radial access.

RESULTS

Over a 2-year span, between June 2016 and May 2018, 59 patients with cerebral aneurysms at different locations were treated by endovascular coiling through transradial access. In two of these 59 patients, two separate aneurysms were treated, since it was impossible to determine which one had caused the patient’s subarachnoid hemorrhage, resulting in a total of 61 aneurysms treated. Of the 59 patients, 39 (66%) were women, and the average age was 48 years. Of the 61 aneurysms treated, eight (13%) were within the posterior circulation (13%), while the remaining 53 (87%) arose within the anterior circulation. The average duration of the procedure was 64.9 min. No occlusion or spasm of the radial artery was observed during any procedure. All patients had immediate postembolization angiography, which revealed the aneurysms occluded with coils and the guide catheter within the right subclavian artery [ Figure 2 ]. A radial pulse was palpable after all 59 interventions.

Figure 2

Diagnostic and post therapeutic control angiographic images. (a) Aneurysm located at the left carotid artery bifurcation, (b) Final post therapeutic control, (c) Final control image showing guide catheter within the subclavian artery, (d) Aneurysm located at the left cerebral media artery bifurcation, (e) Final post therapeutic control, (f) Final control image showing guide catheter within the subclavian artery.

DISCUSSION

In this paper, we describe 61 endovascular coiling procedures performed in 59 subarachnoid hemorrhage patients to treat cerebral aneurysms at a variety of different locations. All 61 aneurysms were accessed by introducing the catheter through the radial artery, an approach that was highly efficient and performed without complications. To date, ours is the largest published series of ruptured cerebral aneurysms embolized by endovascular coiling through the radial artery. We resolved all the cases of this series with coiling technique, but it could have been possible to perform double catheter or remodeling balloon techniques if it would have been necessary.

Radial access is used for angiography and coronary angioplasty procedures worldwide. Some series have been reported on cerebral angiographies performed by transradial access, but the use of this approach to evaluate supra-aortic vessels and to provide endovascular treatment of cerebral aneurysms has, thus far, failed to achieve the same level of acceptance afforded coronary interventions.

Two empirically supported reasons for adopting the radial approach are patient preference and the lower number of complications that occur at the puncture site, relative to the femoral approach.[ 7 , 10 , 16 ] From an anatomical perspective, there are several further advantages of transradial over transfemoral access. First, the radial artery is more superficial and easier to access. Second, again relative to the femoral artery, the radial artery lacks adjacent structures that are susceptible to injury. Third, largely since it is superficial, the radial artery is much more easily compressed, reducing the risk of postprocedural bleeding that might require anticoagulation to be reversed. Overall, transradial artery access is associated with fewer complications.[ 1 , 7 , 10 , 20 ] Moreover, in one survey, patients who underwent radial access coronary catheterization procedures reported a higher quality of life scores than those whose procedure was performed through femoral access.[ 7 ]

CONCLUSIONS

The right transradial approach is an option for the endovascular diagnosis and treatment of cerebral aneurysms of different locations that require a 6Fr or smaller catheter’s size. We observed no topographic limitations or arterial injuries treating aneurysms by this route. This is the largest series of ruptured cerebral aneurysms diagnosed and treated endovascularly through the right radial artery up to date.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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