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Updated: May 2, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Factors of Difficult Guiding Catheter Access in Mechanical Thrombectomy for Acute Ischemic Stroke in the Anterior
Kazuhiro Ando1, Bumpei Kikuchi1, Jun Watanabe1
1Department of Neurosurgery, Niigata Prefectural Central Hospital, Joetsu, Niigata, Japan.
Insights
Difficult guiding catheter access in mechanical thrombectomy is linked to patient age, female sex, shorter height, and specific aortic arch anatomy. Aiming for <20 min insertion improves reperfusion and outcomes in acute ischemic stroke patients.
Area of Science:
- Neurology
- Interventional Radiology
- Vascular Surgery
Background:
- Mechanical thrombectomy (MT) relies on successful guiding catheter (GC) placement.
- Difficult GC access to the target carotid artery can impede treatment for acute ischemic stroke.
- Identifying factors associated with difficult access is crucial for optimizing MT procedures.
Purpose of the Study:
- To assess factors contributing to difficult guiding catheter access in the target carotid artery during MT for anterior circulation acute ischemic stroke.
- To examine the characteristics and outcomes of patients requiring prolonged GC insertion times.
Main Methods:
- Retrospective review of 174 patients undergoing MT.
- Categorization into groups based on groin puncture-to-GC insertion time (<10 min, 10-20 min, >20 min).
- Analysis of patient demographics, anatomical variations (Type III arch, tortuous CCA), and procedural outcomes.
Main Results:
- 8% of patients experienced failed GC access, predominantly older females with height ≤150 cm and specific aortic arch/CCA anatomy.
- GC insertion time significantly correlated with age, Type III arch/CCA tortuosity, and internal carotid artery occlusion.
- Recanalization and 90-day favorable outcomes were lower in patients with GC insertion times >20 min.
Conclusions:
- Efforts should focus on achieving GC insertion within 20 minutes.
- Consider alternative approaches for older patients and those with Type III arch or tortuous common carotid arteries.
- Optimizing GC access is vital for improving MT efficacy and patient outcomes in acute ischemic stroke.
Objective:
Insertion of a guiding catheter (GC) system into the desired arterial site is crucial in mechanical thrombectomy (MT). This study assessed the factors of difficult GC access to the target carotid artery in patients with acute ischemic stroke in the anterior circulation.
Methods:
In total, 174 patients who had undergone MT were retrospectively reviewed. The incidence of patients who could not undergo GC insertion to the target carotid artery, as well as the characteristics and outcomes of patients requiring a longer groin puncture-to-GC insertion time, were examined. The patients were divided into 3 groups based on the time from groin puncture to insertion into the target carotid artery: group A, within 10 min; group B, within 10-20 min; and group C, >20 min. In this study, the transfemoral catheter access was the primary option, and the approach site was changed based on the operator's discretion. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction grade ≥2B. A favorable outcome was defined as a modified Rankin Scale score of 0-2.
Results:
Catheterization of the target carotid artery could not be performed in 8 (4.6%) patients, who were older and more likely to be female. The proportion of patients with a height ≤150 cm and the percentage of patients with a type III arch and/or tortuous common carotid artery (CCA) were high. The approach was changed in 4 (2.3%) patients, and GC insertion was successful in all cases. A significant difference was observed among the 3 groups in terms of age and the percentage of patients with a type III arch and/or CCA tortuosity and internal carotid artery occlusion. In addition, the time from groin puncture to recanalization significantly differed. The recanalization rate and the 90-day favorable outcome rate were significantly lower in patients with a groin puncture-to-GC insertion time >20 min.
Conclusion:
We need to make an effort to insert the GC within 20 min while actively considering changes in the approach, particularly in older patients and those with a type III arch and/or tortuous CCA.
