Trans-radial artery approach

Trans-radial artery approach

Radial artery approach is based on the desire to diminish the incidence rate of haemorrhagic complications in the zone of the puncture and to avoid the necessity of a long-term bed rest in femoral artery approach. The findings obtained in numerous studies of coronary stenting and in a series of works on stenting of carotid arteries have demonstrated that the transradial approach reduces the risk of haemorrhage and local vascular complications.


It is important to be aware Aberrant right subclavian artery (ARSA) before surgical approaches to upper thoracic vertebrae in order to avoid complications and effect proper treatment. In patients with a known ARSA, a right transradial approach for aortography or cerebral angiography should be changed to a left radial artery or transfemoral artery approach 1).


Neurointerventionalists attempting the transradial approach can expect to achieve moderate early success and a low complication rate 2).

They can overcome the right transradial learning curve and achieve high success rates and low crossover rates after performing 30-50 cases 3).


The femoral artery is the most common access route for cerebral angiography and neurointerventional procedures. Complications of the transfemoral approach include groin hemorrhages and hematomas, retroperitoneal hematomas, pseudoaneurysms, arteriovenous fistulas, peripheral artery occlusions, femoral nerve injury, and access-site infections. Incidence rates vary among different randomized and nonrandomized trials, and the literature lacks a comprehensive review of this subject.

Oneissi et al. gather data from 16 randomized clinical trials (RCT) and 17 nonrandomized cohort studies regarding femoral access-site complications for a review paper. They also briefly discussed management strategies for these complications based on the most recent literature.

PubMed indexed search for all neuroendovascular clinical trials, retrospective studies, and prospective studies that reported femoral artery access-site complications in neurointerventional procedures.

The overall access-site complication rate in RCTs is 5.13%, while in non-RCTs, the rate is 2.78%. The most common complication in both groups is groin hematoma followed by access-site hemorrhage and femoral artery pseudoaneurysm. On the other hand, wound infection was the least common complication.

The transfemoral approach in neuroendovascular procedures holds risk for several complications. This review will allow further studies to compare access-site complications between the transfemoral approach and other alternative access sites, mainly the trans-radial artery approach, which is gaining a lot of interest nowadays 4).

Case series

Intra-arterial chemotherapy (IAC) has become one of the most important pillars in retinoblastoma (Rb) management. It allows for targeted delivery of chemotherapy by superselective catheterization of the ophthalmic artery, thus, reducing systemic toxicity. As in most neurovascular procedures, IAC has traditionally been performed through transfemoral access. However, recent publications have spurred the use of the trans-radial route for neuroendovascular procedures due to its lower complication rates and higher patient satisfaction. They presents the first case series in the literature on the technique, safety, and feasibility of IAC via the trans-radial route in the pediatric population.

Al Saiegh et al. retrospectively analyzed the prospectively maintained database and present the technique and initial experience from 5 consecutive pediatric patients aged between 3 and 15 years who underwent 10 trans-radial IAC treatments.

All IACs were performed successfully. Two patients had repeat IACs through the same wrist. There were no thromboembolic events or access site complications, such as hand ischemia or hematoma. All patients were discharged home the same day of the procedure.

This case series demonstrates the safety and feasibility of transradial IAC in pediatric patients with Rb. As more experience is gained with the transradial route for neurovascular procedures in adults, it may become the preferred route in some pediatric patients as well 5).


Chen et al. reviewed a prospective institutional database for all patients who underwent a transradial neurointerventional procedure between 2015 and 2019. Index procedures were defined as procedures performed via TRA after which there was a second TRA procedure attempted. Reasons for conversion to a transfemoral approach (TFA) for subsequent procedures were identified.

104 patients underwent 237 procedures (230 TRA, 7 TFA). 97 patients underwent ≥2 TRA procedures, 20 patients >3, four patients >4, three patients >5, and two patients >6 TRA procedures. The success rate was 94.7% (126/133) with 52% (66/126) of successive procedures performed via the same radial access site (snuffbox vs antebrachial) while the alternate radial artery segment was used for access in 48% (60/126) of subsequent procedures. There were seven (5.3%) cases requiring crossover to TFA, six cases for radial artery occlusion (RAO) and one for radial artery narrowing.

Successive TRA is both technically feasible and safe for neuroendovascular procedures in up to six procedures. The low failure rate (5.3%) was primarily due to RAO. Thus, even without clinical consequences, strategies to minimize RAO should be optimized for patients to continue to benefit from TRA in future procedures 6).


A study from Shchanitsyn et al., was aimed at comparative analysis of the transradial versus transfemoral approach used in carotid stenting. They retrospectively analysed the results of transradial and transfemoral stenting of carotid artery in a total of 168 patients. The operations had been performed in two centres over the period from 2012 to 2017. They evaluated the clinical and angiographic data, technical aspects of the operations, as well as the outcomes and complications. In particular, they compared such complications as stroketransient ischemic attack, myocardial infarction and local complications of the approach. They carried out a univariate analysis of the risk for the development of complications depending on the method of the approach. Stenting of carotid arteries had been performed in 75 patients through the radial artery approach and in 93 patients via the femoral one. Comparing the two groups, the main clinical and angiographic data appeared to have no statistically significant differences. Various techniques of catheterization had been used depending upon anatomical peculiarities. The success of the procedure was achieved in 100% of cases, with the frequency of conversion amounting to 4% for the radial approach and to 1% for the femoral one (p=0.087). Amongst complications encountered, disabling stroke was revealed in two (1.2%) patients and minor stroke in four (2.4%). The groups did not differ by the incidence of neurological complications. Within 30 postoperative days neither lethal outcomes nor myocardial infarction were registered. Neither were there haemorrhagic events or other approach-related complications, however in the transradial-approach group, seven (9.3%) patients were found to have developed asymptomatic occlusions of the radial artery. The duration of the operation, the radiation load, and the length of hospital stay had no statistically significant differences depending on the approach used. Hence, the transradial approach is an effective and safe method in stenting of carotid arteries. In patients with high risk of haemorrhagic complications from the side of the vascular approach and with difficult anatomy of the aortic arch and its branches, hampering catheterization of the carotid artery via the femoral approach, the radial artery may be considered as an advantageous site of access 7).

References

1)

Choi Y, Chung SB, Kim MS. Prevalence and Anatomy of Aberrant Right Subclavian Artery Evaluated by Computed Tomographic Angiography at a Single Institution in Korea. J Korean Neurosurg Soc. 2019 Mar;62(2):175-182. doi: 10.3340/jkns.2018.0048. Epub 2019 Feb 27. PubMed PMID: 30840972; PubMed Central PMCID: PMC6411572.
2)

Zussman BM, Tonetti DA, Stone J, Brown M, Desai SM, Gross BA, Jadhav A, Jovin TG, Jankowitz BT. A prospective study of the transradial approach for diagnostic cerebral arteriography. J Neurointerv Surg. 2019 Mar 6. pii: neurintsurg-2018-014686. doi: 10.1136/neurintsurg-2018-014686. [Epub ahead of print] PubMed PMID: 30842303.
3)

Zussman BM, Tonetti DA, Stone J, Brown M, Desai SM, Gross BA, Jadhav A, Jovin TG, Jankowitz BT. Maturing institutional experience with the transradial approach for diagnostic cerebral arteriography: overcoming the learning curve. J Neurointerv Surg. 2019 Apr 27. pii: neurintsurg-2019-014920. doi: 10.1136/neurintsurg-2019-014920. [Epub ahead of print] PubMed PMID: 31030189.
4)

Oneissi M, Sweid A, Tjoumakaris S, Hasan D, Gooch MR, Rosenwasser RH, Jabbour P. Access-Site Complications in Transfemoral Neuroendovascular Procedures: A Systematic Review of Incidence Rates and Management Strategies. Oper Neurosurg (Hagerstown). 2020 May 4. pii: opaa096. doi: 10.1093/ons/opaa096. [Epub ahead of print] PubMed PMID: 32365203.
5)

Al Saiegh F, Chalouhi N, Sweid A, Mazza J, Mouchtouris N, Khanna O, Tjoumakaris S, Gooch R, Shields CL, Rosenwasser R, Jabbour P. Intra-arterial chemotherapy for retinoblastoma via the transradial route: Technique, feasibility, and case series. Clin Neurol Neurosurg. 2020 Apr 6;194:105824. doi: 10.1016/j.clineuro.2020.105824. [Epub ahead of print] PubMed PMID: 32283473.
6)

Chen SH, Brunet MC, Sur S, Yavagal DR, Starke RM, Peterson EC. Feasibility of repeat transradial access for neuroendovascular procedures. J Neurointerv Surg. 2019 Oct 5. pii: neurintsurg-2019-015438. doi: 10.1136/neurintsurg-2019-015438. [Epub ahead of print] PubMed PMID: 31586940.
7)

Shchanitsyn IN, Sharafutdinov MR, Iakubov RA, Larin IV. [Transradial approach in carotid stenting]. Angiol Sosud Khir. 2018;24(2):114-122. Russian. PubMed PMID: 29924782.

Middle cerebral artery aneurysm case series

Middle cerebral artery aneurysm case series

A study of Gou et al. from the Beijing Neurosurgical Institute, included 285 cases of middle cerebral artery aneurysm surgery with MEP monitoring. The effects of MEP changes on postoperative motor function were assessed, and the key time point for minimizing the incidence of postoperative motor dysfunction was found through receiver operating characteristic (ROC) curve analysis. Motor dysfunction was significantly associated with the occurrence of MEP changes, and patients with irreversible changes were more likely to suffer motor dysfunction than were those with reversible changes. The critical duration of MEP changes that minimized the risk of postoperative motor dysfunction was 8.5 min. This study revealed that MEP monitoring is an effective method for preventing ischemic brain injury during surgical treatment of MCA aneurysm and proposes a critical cutoff for the duration of MEP deterioration of 8.5 min for predicting postoperative motor dysfunction 1).

2018

Esposito et al. from the Department of Neurosurgery, Clinical Neuroscience Center Zurich, report on a consecutive case-series of 50 patients who received clipping of 54 ruptured/unruptured middle cerebral artery aneurysm (MCA-aneurysms) by means of lateral supraorbital approach (LS) or minipterional craniotomy. The distance between MCA (M1)-origin and the aneurysmal neck is key to select the approach: LS was used for MCA-aneurysm located <15mm of the M1-origin and MP for MCA-aneurysms located ≥15mm of the M1-origin.

11 out of 50 patients presented with subarachnoid hemorrhage (10 ruptured MCA aneurysms). Overall, 59 aneurysms were successfully clipped (54 of the MCA). The mean distance between the M1-origin and the aneurysmal neck was 10.1-mm (range: 4-17mm) for patients treated by LS and 20-mm (range: 15-30mm) for MP. All but one MCA aneurysms were successfully treated. At last follow-up (mean 14 months), no reperfusion of the clipped aneurysms was observed.

The strategy for selecting the keyhole approach based on the depth of the aneurysm within the Sylvian fissure is efficient and safe. They suggest the use of LS approach when the aneurysm is located <15mm from the M1-origin and MP approach when the aneurysm is located ≥15mm from the M1-origin 2).

2015

Eighteen intracranial aneurysms, including 13 unruptured and 5 ruptured aneurysms, were treated with LVIS Jr stent-assisted coil embolization.

A total of 18 stents were successfully delivered to the target aneurysms, and the technical success rate was 100%. There was complete occlusion in 8 (44.4%) of 18 cases, neck remnants in 7 (38.9%) cases, and partial occlusion in 3 (16.7%) cases. In-stent thrombosis occurred in 1 case, and the symptoms disappeared after transvenous tirofiban injection. The modified Rankin Scale score at discharge was 0 in 14 patients, 1 in 3 patients, and 2 in 1 patient.

The LVIS Jr stent provided excellent trackability and deliverability and is safe and effective for the treatment of wide-necked MCA aneurysms with tortuous and smaller parent vessels 3).

2014

Clinical and radiological data of 103 patients interdisciplinary treated for unruptured MCA aneurysms over a 5-year period were analyzed in endovascular (n = 16) and microsurgical (n = 87) cohorts. Overall morbidity (Glasgow Outcome Score <5) after 12-month follow-up was 9 %. There was no significant difference between the two cohorts. Complete or “near complete” aneurysm occlusion was achieved in 97 and 75 % in the microsurgical, respective endovascular cohort. A “complex” aneurysm configuration had a significant impact on complete aneurysm occlusion in both cohorts, however, not on clinical outcome. Treatment of unruptured MCA aneurysms can be performed with a low risk of repair using both approaches. However, the risk for incomplete occlusion was higher for the endovascular approach in this series 4).

2013

Five hundred forty-three patients with 631 MCA aneurysms were managed with a “clip first” policy, with 115 patients (21.2%) referred from the Neurointerventional Radiology service and none referred from the Neurosurgical service for endovascular management.

Two hundred eighty-two patients (51.9%) had ruptured aneurysms and 261 (48.1%) had unruptured aneurysms. MCA aneurysms were treated with clipping (88.6%), thrombectomy/clip reconstruction (6.2%), and bypass/aneurysm occlusion (3.3%). Complete aneurysm obliteration was achieved with 620 MCA aneurysms (98.3%); 89.7% of patients were improved or unchanged after therapy, with a mortality rate of 5.3% and a permanent morbidity rate of 4.6%. Good outcomes were observed in 92.0% of patients with unruptured and 70.2% with ruptured aneurysms. Worse outcomes were associated with rupture (P = .04), poor grade (P = .001), giant size (P = .03), and hemicraniectomy (P < .001).

At present, surgery should remain the treatment of choice for MCA aneurysms. Surgical morbidity was low, and poor outcomes were due to an inclusive policy that aggressively managed poor-grade patients and complex aneurysms. This experience sets a benchmark that endovascular results should match before considering endovascular therapy an alternative for MCA aneurysms 5).

1995

Ogilvy et al., reviewed 65 middle cerebral aneurysms in 62 patients operated on over a 5-year interval where a choice of operative approach was made based on preoperative evaluation of available radiological studies.

The superior temporal gyrus was used when intraparenchymal hematoma was present in the temporal lobe or when the length of the middle cerebral artery trunk was long (average length 2.44 +/- 0.41 SE cm). This approach was used in 20 operations on 22 aneurysms. The sylvian fissure approach was used in cases where the middle cerebral artery main trunk was short (1.32 +/- 0.41 SE cm) or the direction of the aneurysm was favorable. This approach was used in 38 operations. In 4 operations (5 aneurysms) we combined the two approaches to remove clot, obtain adequate exposure, and secure control of the proximal MCA.

In most cases of MCA aneurysms the decision as to which surgical approach to use is made preoperatively depending on the presence of intraparenchymal clot, size of aneurysm, direction of aneurysm, and length of the proximal middle cerebral artery 6).

References

1)

Guo D, Fan X, You H, Tao X, Qi L, Ling M, Li Z, Liu J, Qiao H. Prediction of postoperative motor deficits using intraoperative motor-evoked potentials in middle cerebral artery aneurysm. Neurosurg Rev. 2020 Jan 22. doi: 10.1007/s10143-020-01235-0. [Epub ahead of print] PubMed PMID: 31965363.
2)

Esposito G, Dias SF, Burkhardt JK, Fierstra J, Serra C, Bozinov O, Regli L. Selection strategy for optimal keyhole approaches for MCA aneurysms: lateral supraorbital versus minipterional craniotomy. World Neurosurg. 2018 Oct 13. pii: S1878-8750(18)32344-1. doi: 10.1016/j.wneu.2018.09.238. [Epub ahead of print] PubMed PMID: 30326308.
3)

Feng Z, Li Q, Zhao R, Zhang P, Chen L, Xu Y, Hong B, Zhao W, Liu J, Huang Q. Endovascular Treatment of Middle Cerebral Artery Aneurysm with the LVIS Junior Stent. J Stroke Cerebrovasc Dis. 2015 Jun;24(6):1357-62. doi: 10.1016/j.jstrokecerebrovasdis.2015.02.016. Epub 2015 Apr 4. PubMed PMID: 25851343.
4)

Dammann P, Schoemberg T, Müller O, Özkan N, Schlamann M, Wanke I, Sandalcioglu IE, Forsting M, Sure U. Outcome for unruptured middle cerebral artery aneurysm treatment: surgical and endovascular approach in a single center. Neurosurg Rev. 2014 Oct;37(4):643-51. doi: 10.1007/s10143-014-0563-5. Epub 2014 Jul 9. PubMed PMID: 25005630.
5)

Rodríguez-Hernández A, Sughrue ME, Akhavan S, Habdank-Kolaczkowski J, Lawton MT. Current management of middle cerebral artery aneurysms: surgical results with a “clip first” policy. Neurosurgery. 2013 Mar;72(3):415-27. doi: 10.1227/NEU.0b013e3182804aa2. PubMed PMID: 23208060.
6)

Ogilvy CS, Crowell RM, Heros RC. Surgical management of middle cerebral artery aneurysms: experience with transsylvian and superior temporal gyrus approaches. Surg Neurol. 1995 Jan;43(1):15-22; discussion 22-4. PubMed PMID: 7701417.

Middle cerebral artery

Middle cerebral artery

The middle cerebral artery (MCA) is the largest and most complex of the three major cerebral arteries 1).

Most of the authors who have carried out anatomical studies of the middle cerebral artery agree on this being one of the least variable arteries. Nevertheless, they describe early bifurcationtrifurcationquadrifurcationduplication, single non-bifurcating trunk, hypoplasiafenestrations, etc. Considered to be having one of the most extensive irrigation territories in the brain. The artery arises below the anterior perforated substance, lateral to the optic chiasm. It runs along the sylvian fissure up to the limen insulae, where it bends at an angle which can be upto 90° and it is at that point where the bifurcation usually occurs.

The MCA arises from the internal carotid artery and continues into the lateral sulcus where it then branches and projects to many parts of the lateral cerebral cortex. It also supplies blood to the anterior temporal lobes and the insula. The artery supplies a portion of the frontal lobe and the lateral surface of the temporal and parietal lobes, including the primary motor and sensory areas of the face, throat, hand and arm, and in the dominant hemisphere, the areas for speech.

The left and right MCAs rise from trifurcations of the internal carotid arteries and thus are connected to the anterior cerebral artery and the posterior communicating artery, which connect to the posterior cerebral artery. The MCAs are not considered a part of the Circle of Willis.

The angular artery is a significant terminal branch of the anterior or middle trunk of the middle cerebral artery (MCA).

Variations

Duplicated middle cerebral artery.

Accessory Middle cerebral artery 2).

Teal et al. 3) further classified two types of accessory MCAs based on the origin of variant vessels, which can be proximal (type 1) or distal (type 2) segments of the ACA 4).

Classification

MCA was studied by Gunnal et al., in detail and classified it in four different types as bifurcated, trifurcated, quadrifurcated MCA and MCA with no trunks or single main trunk as per the termination 5).

Kahilogullari et al. proposed a way of classification made in relation to the terminology of the intermediate trunk, which is still a subject of debate. The intermediate trunk was present in 61% of cadavers and originated from a superior trunk in 55% and from an inferior trunk in 45%. Cortical branches supplying the motor cortex (precentral, central, and postcentral arteries) significantly originated from the intermediate trunk, and the diameter of the intermediate trunk significantly increased when it originated from the superior trunk. In measurements of the angles between the superior and intermediate trunks, it was found that the intermediate trunk had significant dominance in supplying the motor cortex as the angle increased. The intermediate trunk was classified into 3 types based on the angle values and the distance to the bifurcation point as Group A (pseudotrifurcation type), Group B (proximal type), and Group C (distal type). Group A trunks were seemingly closer to the trifurcation structure that has been reported on in the literature and was seen in 15%. Group B trunks were the most common type (55%), and Group C trunks were characterized as the farthest from the bifurcation point. Group C trunks also had the smallest diameter and fewest cortical branches. Similarities were found between the angles in cadaver specimens and on 3D CT cerebral angiography images. Beyond the separation point of the MCA, trunk structures always included the superior trunk and inferior trunk, and sometimes the intermediate trunk.

Interrelations of these vascular structures and their influences on the cortical branches originating from them are clinically important. The information presented in this study will ensure reliable diagnostic approaches and safer surgical interventions, particularly with MCA selective angiography 6).

Areas

The MCA territory was divided into 12 areas: orbitofrontal, prefrontal, precentral, central, anterior parietal, posterior parietal, angular, temporo-occipital, posterior temporal, middle temporal, anterior temporal, and temporopolar. The smallest cortical arteries arose at the anterior end and the largest one at the posterior end of the Sylvian fissure. The largest cortical arteries supplied the temporo-occipital and angular areas 7).

Perforators

Three distinct patterns of perforators arising from the proximal middle cerebral artery were found 8).


Marinković et al., divided it into medial, middle, and lateral groups. Those in the medial group usually arose directly from the MCA main trunk close to the carotid bifurcation. There were usually three vessels in the middle group, which originated not only from the MCA trunk, but also from the MCA collateral (cortical) branches. Common stems, when present, gave rise to individual perforating vessels and occasionally to thin olfactory and insular rami. Perforating arteries in the lateral group varied from one to nine in number. In addition to an origin from the MCA trunk, they also arose from cortical branches supplying the frontal and temporal lobes. The fact that lateral perforating vessels often originated from division sites and from terminal branches of the MCA is of clinical significance, because aneurysms are more commonly located at the MCA bifurcation. Anastomoses were not found among the perforating arteries. In two specimens, a fusion between a perforating artery and the MCA trunk was noted. Since the perforating vessels are obviously end arteries, injury to them must be avoided during operations for MCA aneurysms 9).

Segments

Branches

Pathology

References

1)

Rhoton AL., Jr The supratentorial arteries. Neurosurgery. 2002;51(Suppl 4):53–120.
2)

Uchino A, Kato A, Takase Y, Kudo S. Middle cerebral artery variations detected by magnetic resonance angiography. Eur Radiol. 2000;10(4):560-3. PubMed PMID: 10795531.
3)

Teal JS, Rumbaugh CL, Bergeron RT, Segall HD. Anomalies of the middle cerebral artery: accessory artery, duplication, and early bifurcation. Am J Roentgenol Radium Ther Nucl Med. 1973 Jul;118(3):567-75. PubMed PMID: 4723180.
4) , 7)

Gibo H, Carver CC, Rhoton AL Jr, Lenkey C, Mitchell RJ. Microsurgical anatomy of the middle cerebral artery. J Neurosurg. 1981 Feb;54(2):151-69. PubMed PMID: 7452329.
5)

Gunnal SA, Farooqui MS, Wabale RN. Study of Middle Cerebral Artery in Human Cadaveric Brain. Ann Indian Acad Neurol. 2019 Apr-Jun;22(2):187-194. doi: 10.4103/0972-2327.144289. PubMed PMID: 31007431; PubMed Central PMCID: PMC6472224.
6)

Kahilogullari G, Ugur HC, Comert A, Tekdemir I, Kanpolat Y. The branching pattern of the middle cerebral artery: is the intermediate trunk real or not? An anatomical study correlating with simple angiography. J Neurosurg. 2012 May;116(5):1024-34. doi: 10.3171/2012.1.JNS111013. Epub 2012 Feb 24. PubMed PMID: 22360571.
8)

Grand W. Microsurgical anatomy of the proximal middle cerebral artery and the internal carotid artery bifurcation. Neurosurgery. 1980 Sep;7(3):215-8. PubMed PMID: 7207737.
9)

Marinković SV, Kovacević MS, Marinković JM. Perforating branches of the middle cerebral artery. Microsurgical anatomy of their extracerebral segments. J Neurosurg. 1985 Aug;63(2):266-71. PubMed PMID: 4020447.
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