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Carotid artery direct access for mechanical thrombectomy: the Carotid Artery Puncture Evaluation (CARE) study
Victor Dumas1, Johannes Kaesmacher2, Julien Ognard3
1Radiology Department, Poitiers University Medical Center, LabCom I3M, DACTIM-MIS team, LMA CNRS 7348, Poitiers, Vienne, France dumasvictor@outlook.fr.
Insights
Direct carotid artery puncture (DCP) for mechanical thrombectomy (MT) in acute ischemic stroke is rare but carries a high complication rate. Manual compression after DCP may be unnecessary, as it did not prevent complications in this study.
Area of Science:
- Neurology
- Interventional Neuroradiology
- Vascular Surgery
Background:
- Mechanical thrombectomy (MT) is a crucial treatment for acute ischemic stroke due to anterior large vessel occlusion (AIS-LVO).
- The femoral approach for MT can be challenging, necessitating alternative vascular access methods.
- Direct carotid artery puncture (DCP) is an alternative access route when standard methods fail.
Purpose of the Study:
- To evaluate the safety and efficacy of direct carotid artery puncture (DCP) for MT in patients with AIS-LVO.
- To identify risk factors associated with complications following DCP.
Main Methods:
- Retrospective analysis of 108 patients undergoing DCP for MT across 45 centers from January 2015 to July 2019.
- Data collection included baseline characteristics, procedural details, and clinical outcomes.
- Uni- and multivariable models were used to assess complication risks.
Main Results:
- DCP was performed in 0.39% of MT cases.
- Successful reperfusion (mTICI ≥2b) was achieved in 71.3% of patients after DCP.
- A complication rate of 18.5% was observed, with no deaths directly attributed to DCP in the long term.
- Absence of a hemostatic closure device was linked to increased complication risk (OR 3.04).
Conclusions:
- Direct carotid artery puncture (DCP) is a rarely used but viable option for MT in select AIS-LVO patients.
- The complication rate associated with DCP is significant (18.5%).
- Findings suggest that manual compression for cervical access closure post-MT may not be necessary.
Background:
In acute ischemic stroke due to anterior large vessel occlusion (AIS-LVO), accessing the target occluded vessel for mechanical thrombectomy (MT) is sometimes impossible through the femoral approach. We aimed to evaluate the safety and efficacy of direct carotid artery puncture (DCP) for MT in patients with failed alternative vascular access.
Methods:
We retrospectively analyzed data from 45 stroke centers in France, Switzerland and Germany through two research networks from January 2015 to July 2019. We collected physician-centered data on DCP practices and baseline characteristics, procedural variables and clinical outcome after DCP. Uni- and multivariable models were conducted to assess risk factors for complications.
Results:
From January 2015 to July 2019, 28 149 MT were performed, of which 108 (0.39%) resulted in DCP due to unsuccessful vascular access. After DCP, 77 patients (71.3%) had successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) score ≥2b) and 28 (25.9%) were independent (modified Rankin Scale (mRS) score 0-2) at 3 months. 20 complications (18.5%) attributed to DCP occurred, all of them during or within 1 hour of the procedure. Complications led to extension of the intubation time in the intensive care unit in 7 patients (6.4%) and resulted in death in 3 (2.8%). The absence of use of a hemostatic closure device was associated with a higher complication risk (OR 3.04, 95% CI 1.03 to 8.97; p=0043).
Conclusion:
In this large multicentric study, DCP was scantly performed for vascular access to perform MT (0.39%) in patients with AIS-LVO and had a high rate of complications (18.5%). Our results provide arguments for not closing the cervical access by manual compression after MT.
