Hi, my name is Joshua Katapano. I'm a fourth-year resident at the Barrow Neurological Institute. I will be presenting today, Complications of Femoral vs. Radial Axis in Neuroendovascular Procedures with Propensity Adjustment. I wanted to thank the AANS for letting me present this article. There are no disclosures to report. Introduction. The radial artery approach has become an increasingly popular alternative for arterial axis endovascular interventions. Compared to the traditional femoral artery access, transradial axis interventional cardiology has been found to be superior in terms of clinical outcomes, patient satisfaction, and cost reduction. They found reduced bleeding, major vascular complications, overall adverse clinical events, and a reduction in hospital length of stay. Transradial axis approaches provide several advantages in neuroendovascular procedures from prior literature. One, more direct access to the vertebral basilar system. Second, there's an ease navigating complex arch anatomies, for example, a bovine or type III arches. Third, robust collateral circulation from the ulnar artery. This allows for fewer ischemic, and if there were to cure, often clinically silent complications. Variations to the traditional proximal transradial approach do exist. There's a distal transradial approach within the anatomic snuff box or radial fossa. This allows for arterial access distal to the branch point of the superficial palmar branch supplying collaterals to the deep palmar arch of the hand. Theoretically, there's even a greater decrease risk of ischemic complications. And literature has shown that you're still able to use large-bore coaxial systems for these procedures. The American Heart Association guidelines recommend a radial first strategy for acute coronary syndrome patients currently. However, this paradigm shift is still lagging in the neurointerventional field. This is largely due to lack of operator experience and large studies comparing neurointerventional results. The present study compares the risk of complication via propensity-adjusted analysis and neuroendovascular procedures with a transradial access versus a transfemoral access approach at a single center. Methods. This is a retrospectively reviewed study where all patients who underwent a neuroangiographic procedure at a single center from October 1, 2018, to June 30, 2019, were analyzed. Procedures were separated into groups. One, diagnostic angiography and or vasospasm treatment. And second, specific treatments. Access sites were categorized as either transradial access, included both the distal or snuffbox approach, and the proximal or wrist access, or the transfemoral access. Complications were categorized as either minor, such as access site hemorrhages that did not require treatment, small hematomas, or major, which included vessel dissection, perforations, thromboembolic events, intracranial hemorrhages, retroperineal hemorrhages, and vessel occlusions. A propensity analysis was performed. In this analysis, we adjusted for age, sex, sheath, catheter size, procedure, and angiographic pathology. This was performed to analyze the risks of access site complications via a multivariant logistic regression analysis, and then also a linear regression analysis for efficiency was performed. Efficiency was measured as either fluoroscopy time or volume of contrast used. Results. Here's figure one. This figure is a bar graph showing the transradial procedures that were performed at our institution starting from October 1, 2018, where we performed our first transradial approach. As you can see, over this nine-month period, there was a substantial increase in the amount of procedures we performed from October all the way to June 2019. As we became more comfortable with the procedure, as well as saw that there was a decreased risk of complications with this procedure. Here's table one, which shows the characteristics of patients undergoing angiographic procedures by access site. There was a total of 206 radial procedures and 844 femoral procedures during the study period. There was a significant difference in procedure type, with a much higher percentage of patients undergoing a thrombectomy in the femoral group versus the radial group. There was also a 10% difference in diagnostic angiograms, such as phasal spasm treatment in the radial versus femoral group. Significant difference in pathology, higher percentage of normal pathology in the radial group, as well as aneurysms. And there was a higher percentage of acute strokes in the femoral group, similar to what we saw with the procedures with a higher percentage of thrombectomies. There was also an increase in sheath size in the femoral group versus the radial group with a significant difference. Here's table two, showing the comparisons of intra-procedural variables outcomes by access site during angiography. There was a significant increase in fluoroscopy time in the radial versus femoral group, 40 versus 30 minutes. There was almost a 20cc difference, with an increased total contrast amount in the radial group versus the femoral group. And total complications, there was an increased percentage of total complications in the femoral group at 7% versus the radial group at only 2%. As you see, the total minor complications were significantly different, with 6% in the femoral versus only 2% in the radial group. There was only one major complication in the radial group versus 13 in the femoral group. Then when you look at diagnostic and basal spasm complications for those relatively benign procedures, there was a large increase in the femoral group versus radial at 6% versus 1%, with only one patient in the radial group having a complication. Table three shows the characteristics and comparison of radial access procedures categorized as either distal or snuffbox versus the proximal wrist access. Largely, they were very similar. There was a difference in sheath size, with the proximal access having larger sheath sizes than the distal snuffbox access, as well as catheter size. Similarly, it was found with larger sizes in the proximal versus distal group. Vorosimetry time was actually lower in the distal snuffbox group at 19 minutes versus the proximal group at 24 minutes. Here's table four, showing the propensity adjusted predictors of outcomes for femoral access versus radial access. Femoral access was found to be a predictor of a complication. It was found to have four minutes less in fluoroscopy time, and was found to be associated with 10 cc less in contrast amounts after propensity adjustment. Discussion. After propensity adjusted analysis, transfemoral artery procedures were found to be a major risk factor for a complication compared with transradial artery procedures. There was no life-threatening complication with the transradial artery procedure, while five major complications in the transfemoral artery approach were life-threatening, including two occlusive and near-occlusive femoral arteries, one retroperitoneal bleed, and two large intracranial hemorrhages. Diagnostic procedures with transfemoral artery approaches were found to have an increased complication rate as well. These are relatively benign procedures. Theoretically, transradial artery makes these even safer. There is a steep learning curve for the transradial artery procedure discussed in previous literature. Complications did occur in our study in the first 60 transradial artery cases, and there were none afterwards. There was no significant difference in the percent of procedures that could not be completed and needed crossover between the approaches, however. In linear regression propensity-adjusted analysis, mean fluoroscopy time was found to be four minutes less with the transfemoral artery procedures. However, transradial artery fluoroscopy time was greatest in the first 40 cases, 41 minutes versus only 36 minutes in the remaining cases. There was no significant difference in axis-side crossovers or complication rates between the proximal and distal radial axis. Mean fluoroscopy time was five minutes shorter in the distal radial axis, however this is likely due to distal procedures being performed during the latter part of the study and greater operator expertise. Larger sheath and catheter size were found in the proximal radial axis approaches versus distal. This is likely due to a larger number of treatments performed in these procedures. In conclusion, the transradial artery approach for neuroendovascular procedures appears to be safer than the standard transfemoral artery approach. The distal stuffed box radial axis has a similar low risk of complications than more proximal radial axis approaches. Although a steep learning curve is initially encountered when using the transradial artery approach, our results suggest that the transition to a transradial artery first practice can be performed safely with minimal loss in efficiency. I would like to thank Dr. Albuquerque, who is the corresponding author for this study, as well as Dr. Ducre.

Complications

Femoral vs. Radial Axis

Neuroendovascular Procedures

Clinical Outcomes

Transradial Artery Approach