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Updated: Jan 28, 2026
Simulator Training for Endovascular Neurosurgery
Published on: May 6, 2020
A Retrospective Propensity-Matched Analysis of Functional Outcomes for Carotid Puncture for Endovascular Thrombectomy
Andrew T Yu1, Joey Knox2, Fei Jiang3
1UCSF Weill Institute for Neurosciences Department of Neurology Neurovascular and Neurocritical Care Division University of California San Francisco CA.
Insights
Direct carotid puncture (DCP) did not worsen outcomes for large-vessel occlusion stroke patients undergoing endovascular thrombectomy. This study found no significant difference in functional outcomes between DCP and other access methods after propensity score matching.
Area of Science:
- Neurology
- Interventional Cardiology
- Vascular Surgery
Background:
- Endovascular thrombectomy is crucial for large-vessel occlusion stroke, with reperfusion time being a key factor.
- Direct carotid puncture (DCP) bypasses aortic arch challenges, potentially reducing delays.
- Observed poorer outcomes with DCP may stem from patient selection bias rather than the technique itself.
Purpose of the Study:
- To evaluate the functional outcomes of endovascular thrombectomy using direct carotid puncture (DCP) versus other access methods.
- To mitigate confounding by indication using a propensity score-matched case-control design.
- To determine if DCP itself impacts patient outcomes in large-vessel occlusion stroke.
Main Methods:
- A propensity score-matched case-control study analyzed patients undergoing endovascular thrombectomy under general anesthesia from 2015-2021.
- Data included baseline characteristics, workflow times, aortic arch measurements, and 90-day modified Rankin scale (mRS).
- Propensity scores were generated using sex, age, NIH Stroke Scale, and last seen normal-to-groin times for matching.
Main Results:
- The final analysis included 13 DCP patients and 67 controls, with DCP patients being significantly older (85.4 vs. 73.8 years).
- After propensity score matching, no significant difference in mean mRS was found between the DCP and control groups (β=-0.231, P=0.676).
- This indicates DCP was not associated with differential functional outcomes.
Conclusions:
- Direct carotid puncture (DCP) is not associated with worse functional outcomes compared to other access methods for endovascular thrombectomy in large-vessel occlusion stroke.
- Further advancements in identifying patients likely to need DCP and in carotid closure devices are necessary for broader adoption.
- The study suggests that patient selection, not the DCP technique, may explain previously observed outcome disparities.
Background:
Endovascular thrombectomy is a well-established therapy for patients with large-vessel occlusion stroke but its success largely depends on minimizing time to reperfusion. Direct carotid puncture (DCP) is a technique that avoids difficult aortic arch anatomy, which may cause intraprocedural delays, but because DCP is typically used as rescue access, the poorer outcomes that some have observed may reflect differences in patients chosen for DCP rather than the impact of DCP itself. We performed a propensity score-matched case-control study to try to address potential confounding by indication to better evaluate whether the DCP procedure itself is responsible for differences in functional outcomes.
Methods:
We identified all DCP cases and non-DCP endovascular thrombectomy controls that were performed under general anesthesia at 2 academic medical centers from 2015 to 2021. Baseline characteristics, workflow time metrics, aortic arch measurements, and 90-day modified Rankin scale were abstracted from the electronic health record. We then matched patients with controls based on propensity scores, then performed a linear regression to evaluate the relationship between DCP and 90-day modified Rankin scale.
Results:
We identified 13 patients with DCP and 67 control patients for our final analysis. The mean age for DCP was 85.4 years compared with 73.8 years in the control group (P≤0.001). We used sex, age, National Institutes of Health Stroke Scale, and last seen normal-to-groin times to generate a propensity score to estimate each patient's likelihood of receiving DCP. After matching, we found no significant difference in mean modified Rankin scale associated with DCP (β=-0.231, standard error 0.545; P=0.676).
Conclusions:
After propensity-score matching, we found that DCP was not associated with a difference in functional outcomes of endovascular thrombectomy for large-vessel occlusion stroke compared with non-DCP access. Advances in algorithms to identify patients highly likely to require DCP and in devices for safer carotid closure are needed before wider adoption of DCP.
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