Worse clinical outcomes in stroke patients with difficult catheter access in endovascular procedures


Marc Ribo, Unitat d’lctus, Hospital Vall d’Hebron, Barcelona, Spain, and colleagues, in a study published ahead-of-print in the Journal of Neurointerventional Surgery, said that difficult catheter access to the carotid artery during endovascular treatment of stroke patients is common and is associated with worse clinical outcomes.

The aim outlined in the study was to analyse the incidence and impact of a difficult transfemoral catheter access to the carotid artery on clinical outcome in acute ischaemic stroke patients who underwent endovascular procedures of which the data were prospectively recorded in a database and studied.

The authors, after femoral access was secured with an 11cm 8F sheath, attempted to catheterise the carotid artery ipsilateral to the intracranial occlusion followed by an angiogram to locate the target carotid. A 0.035 inch stiff guidewire was used to advance the guiding sheath with the Merci Balloon Guide Catheter (Concentric Medical/Stryker) or the Flexor Tuohy-Borst Side-Arm (Cook Medical). Follow-up was undertaken, by a neurologist, at 24 hours and seven days using the National Institutes of Health Stroke Scale (NIHSS) score.

Of the 130 patients included in the study, catheterisation of the target carotid artery was impossible in seven patients (5.4%) of which two had Leriche syndrome and five had an extremely tortuous aortic arch. These patients had significantly lower rates of recanalisation (14.3% vs. 80.5%; p<0.01) and a less favourable outcome (0% vs. 36%; p=0.038), the authors found.

The results also showed that the patients with an accessible carotid artery were considered to have difficult catheter access if time from arterial puncture to carotid catheterisation was >30 minutes. A negative correlation was found between time to carotid access and final recanalisation (r=–0.31, p<0.01). The authors also found, that patients with difficult catheter access also had a significantly longer procedure time but similar time from symptom onset to final recanalisation. At three months: “The rate of favourable outcome progressively decreased according to catheterisation time,” said Ribo et al. “However, the lower final recanalisation rates and longer procedure time after carotid catheterisation could be attributed, at least in part, to difficult access and proximal vessel tortuosity.”

“Difficult access is associated with worse clinical outcome. If catheter access through the femoral artery appears difficult, alternative access, such as direct carotid puncture, could be explored,” the authors concluded.