Letter to the Editor
Humeral arterial access: An alternative route to the femoral artery in the endovascular treatment of acute stroke
El acceso arterial humeral: una vía alternativa al acceso femoral en el tratamiento endovascular del ictus agudo
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Matias-Guiu, C. Serna-Candel, A. Gil, L. Lopez-Ibor" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J.A." "apellidos" => "Matias-Guiu" "email" => array:1 [ 0 => "jordimatiasguiu@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Serna-Candel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Gil" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Lopez-Ibor" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neurología, Unidad de Ictus y Unidad de Neurorradiología intervencionista, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Neurorradiología Intervencionista, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El acceso arterial humeral: una vía alternativa al acceso femoral en el tratamiento endovascular del ictus agudo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The femoral artery is the vascular access route most commonly used in cerebral endovascular procedures. Nevertheless, access at this site is impossible in a number of situations, such as atheromatosis of the femoral arteries, elongation of the supra-aortic trunks, and anatomical variations of the aortic arch.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> When the femoral access cannot be used, endovascular therapy may be delayed or even contraindicated according to some protocols. Here, we describe the case of 2 patients with ischaemic stroke who were able to undergo endovascular treatment by means of a brachial approach only.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Case 1: male patient aged 45 years, diagnosed with basilar artery thrombosis, who arrived at the angiography room 6<span class="elsevierStyleHsp" style=""></span>h and 20<span class="elsevierStyleHsp" style=""></span>min after symptom onset. Twenty minutes later, a usable femoral access was obtained. However, even after multiple attempts, the right vertebral artery could not be catheterised due to arterial elongations (the left vertebral artery was hypoplastic). We therefore used a right transbrachial approach and achieved basilar artery recanalisation 33<span class="elsevierStyleHsp" style=""></span>min after puncture.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Case 2: male patient aged 71 years with a history of peripheral artery disease. He arrived at the angiography room with an ischaemic stroke in the territory of the left sylvian artery due to an M1 proximal occlusion evolving over 4<span class="elsevierStyleHsp" style=""></span>h and 5<span class="elsevierStyleHsp" style=""></span>min. Angiography of the aortoiliac axis through the femoral access showed pre-occlusive stenosis of the right iliac artery with occlusion of the left iliac artery. After 4<span class="elsevierStyleHsp" style=""></span>h and 50<span class="elsevierStyleHsp" style=""></span>min of onset, we gained access through the right brachial vein and then recanalised the medial cerebral artery in 49<span class="elsevierStyleHsp" style=""></span>min.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The transfemoral approach (Seldinger technique) is the standard access route for neurovascular surgical procedures, as it allows the use of larger devices and provides better navigation capabilities. The dose of radiation is lower, and the femoral artery has a low thrombotic complication rate. The axillary, humeral and radial puncture sites are all included in the brachial approach. The axillary artery allows use of 8 French introducers. However, the risk of haematoma is higher since haemostatic compression is more difficult at this site. Although the humeral artery allows use of introducers of up to 6 French and offers easy access, the risk of arterial thrombosis is high in prolonged procedures. The radial artery allows use of introducers as large as 6 French, but the risk of arterial thrombosis can be as high as 10%. Over the past few years, we have read published results from isolated series in which transradial or transbrachial approaches were used for diagnostic cerebral arteriography,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and for stents in stenosis of the anterior and posterior circulation.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Using a radial or brachial access eliminates the risk of retroperitoneal haemorrhage and allows the patient to resume walking early on. This alternative is used when vessel tortuosity makes it difficult or impossible to reach the vertebral artery via the femoral artery. Nevertheless, for purposes of the current endovascular treatment for acute stroke, the smaller diameter of the brachial artery limits the gauge of the introducer normally used with 7 or 8 French balloon-tipped guide catheters needed for aspiration thrombectomy. It also limits use of devices needing catheters with a larger internal lumen. Other factors, such as lack of experience with this approach and its increased complexity, which may prolong the procedure, also limit the use of brachial access as a first-choice surgical option in acute stroke. Nevertheless, there are no controlled clinical trials comparing the efficacy and safety of the different approaches. The fact that new devices are being designed could change that situation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Two extensive meta-analyses were recently published which compare transradial and transfemoral access for percutaneous coronary intervention procedures.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Although the transradial approach leads to very few local complications, the procedure failure rate is significantly higher than that of the transfemoral approach (7.2% vs 2.4%). This is due to either the difficulty of re-canalising the radial artery or subsequent problems with manipulating the catheter.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">During the acute phase of stroke, endovascular treatment may be delayed or even discontinued when the femoral approach does not allow access to the thrombosed cerebral artery (aortoiliac occlusion, severe vascular elongation, etc.). In such cases, we should consider the brachial approach as an alternative which could compensate for potential delays in providing this urgent treatment. It has been proven that “time is brain” and neurovascular surgical procedures are often carried out within short time windows. Furthermore, atherosclerosis is a systemic disease, and it is common for patients with ischaemic stroke to suffer from peripheral artery disease as well.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the cases described here, we could not use a femoral approach due to artery elongation or severe peripheral artery disease. This delayed the endovascular procedure, but the brachial approach enabled quick access to treatment. Given that the increasing use of endovascular procedures during the acute phase of stroke and the need to begin treatment as soon as possible, it is advisable to optimise all measures that potentially prevent treatment delay. We should be aware that vascular access route is an important factor that needs to be evaluated in future studies.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Matias-Guiu JA, et al. El acceso arterial humeral: una vía alternativa al acceso femoral en el tratamiento endovascular del ictus agudo. Neurología. 2012;27:448–9.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tecniques and devices in interventional neuroradiology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.M. Katz" 1 => "P.Y. Gobin" 2 => "H.A. Riina" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Interventional neuroradiology" "paginaInicial" => "161" "paginaFinal" => "181" "serieFecha" => "2008" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transradial cerebral angiography: an alternative route" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.I. Levy" 1 => "A.S. Boulos" 2 => "R.D. Fessler" 3 => "B.R. Bendok" 4 => "A.K. Ringer" 5 => "S.H. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Neurosurgery" "fecha" => "2002" "volumen" => "51" "paginaInicial" => "335" "paginaFinal" => "340" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12182771" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Carotid artery stenting via transbrachial approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.W. Tietke" 1 => "S. Ulmer" 2 => "C. Riedel" 3 => "O. Jansen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1055/s-2008-1027707" "Revista" => array:6 [ "tituloSerie" => "Rofo" "fecha" => "2008" "volumen" => "180" "paginaInicial" => "988" "paginaFinal" => "993" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18855301" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transradial approach for stenting of vertebrobasilar stenosis: a feasibility study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T. Patel" 1 => "S. Shah" 2 => "H. Malhotra" 3 => "R. Radadia" 4 => "L. Shah" 5 => "S. Shah" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ccd.22129" "Revista" => array:6 [ "tituloSerie" => "Catheter Cardiovasc Interv" "fecha" => "2009" "volumen" => "74" "paginaInicial" => "925" "paginaFinal" => "931" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19496123" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; systematic overview and meta-analysis of randomized trials" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Agostoni" 1 => "G.G. Biondi-Zoccai" 2 => "M.L. De Benedictis" 3 => "S. Rigattieri" 4 => "M. Turri" 5 => "M. Anselmi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2004.04.034" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2004" "volumen" => "44" "paginaInicial" => "349" "paginaFinal" => "356" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15261930" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.S. Jolly" 1 => "S. Amlani" 2 => "M. Hamon" 3 => "S. Yusuf" 4 => "S.R. Mehta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ahj.2008.08.023" "Revista" => array:6 [ "tituloSerie" => "Am Heart J" "fecha" => "2009" "volumen" => "157" "paginaInicial" => "132" "paginaFinal" => "140" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19081409" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of asymptomatic peripheral artery disease in patients with non-cardioembolic ischemic stroke" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Álvarez-Sabín" 1 => "A. Gil-Núñez" 2 => "M. Quintana" 3 => "G. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 1 | 3 |
| 2024 October | 19 | 4 | 23 |
| 2024 September | 22 | 7 | 29 |
| 2024 August | 25 | 10 | 35 |
| 2024 July | 23 | 7 | 30 |
| 2024 June | 18 | 2 | 20 |
| 2024 May | 26 | 10 | 36 |
| 2024 April | 21 | 31 | 52 |
| 2024 March | 29 | 8 | 37 |
| 2024 February | 40 | 3 | 43 |
| 2024 January | 25 | 13 | 38 |
| 2023 December | 35 | 9 | 44 |
| 2023 November | 27 | 1 | 28 |
| 2023 October | 48 | 8 | 56 |
| 2023 September | 25 | 4 | 29 |
| 2023 August | 23 | 6 | 29 |
| 2023 July | 31 | 12 | 43 |
| 2023 June | 53 | 4 | 57 |
| 2023 May | 60 | 5 | 65 |
| 2023 April | 45 | 4 | 49 |
| 2023 March | 36 | 4 | 40 |
| 2023 February | 45 | 5 | 50 |
| 2023 January | 28 | 13 | 41 |
| 2022 December | 36 | 3 | 39 |
| 2022 November | 31 | 11 | 42 |
| 2022 October | 28 | 14 | 42 |
| 2022 September | 32 | 15 | 47 |
| 2022 August | 39 | 15 | 54 |
| 2022 July | 15 | 15 | 30 |
| 2022 June | 25 | 8 | 33 |
| 2022 May | 18 | 7 | 25 |
| 2022 April | 18 | 12 | 30 |
| 2022 March | 31 | 9 | 40 |
| 2022 February | 22 | 5 | 27 |
| 2022 January | 41 | 7 | 48 |
| 2021 December | 17 | 15 | 32 |
| 2021 November | 22 | 9 | 31 |
| 2021 October | 31 | 10 | 41 |
| 2021 September | 23 | 14 | 37 |
| 2021 August | 41 | 7 | 48 |
| 2021 July | 37 | 7 | 44 |
| 2021 June | 27 | 8 | 35 |
| 2021 May | 27 | 7 | 34 |
| 2021 April | 59 | 13 | 72 |
| 2021 March | 39 | 14 | 53 |
| 2021 February | 17 | 10 | 27 |
| 2021 January | 20 | 12 | 32 |
| 2020 December | 26 | 13 | 39 |
| 2020 November | 26 | 9 | 35 |
| 2020 October | 23 | 7 | 30 |
| 2020 September | 19 | 8 | 27 |
| 2020 August | 31 | 9 | 40 |
| 2020 July | 25 | 14 | 39 |
| 2020 June | 30 | 6 | 36 |
| 2020 May | 29 | 15 | 44 |
| 2020 April | 13 | 10 | 23 |
| 2020 March | 20 | 11 | 31 |
| 2020 February | 29 | 5 | 34 |
| 2020 January | 21 | 8 | 29 |
| 2019 December | 36 | 7 | 43 |
| 2019 November | 21 | 9 | 30 |
| 2019 October | 26 | 0 | 26 |
| 2019 September | 33 | 13 | 46 |
| 2019 August | 13 | 4 | 17 |
| 2019 July | 15 | 13 | 28 |
| 2019 June | 36 | 28 | 64 |
| 2019 May | 111 | 30 | 141 |
| 2019 April | 45 | 8 | 53 |
| 2019 March | 11 | 4 | 15 |
| 2019 February | 12 | 10 | 22 |
| 2019 January | 10 | 6 | 16 |
| 2018 December | 5 | 6 | 11 |
| 2018 November | 12 | 4 | 16 |
| 2018 October | 8 | 10 | 18 |
| 2018 September | 7 | 6 | 13 |
| 2018 August | 1 | 7 | 8 |
| 2018 July | 3 | 9 | 12 |
| 2018 June | 3 | 5 | 8 |
| 2018 May | 3 | 16 | 19 |
| 2018 April | 0 | 3 | 3 |
| 2018 March | 2 | 1 | 3 |
| 2018 February | 1 | 4 | 5 |
| 2018 January | 1 | 0 | 1 |
| 2017 December | 1 | 4 | 5 |
| 2017 November | 2 | 4 | 6 |
| 2017 October | 10 | 4 | 14 |
| 2017 September | 17 | 7 | 24 |
| 2017 August | 12 | 17 | 29 |
| 2017 July | 7 | 6 | 13 |
| 2017 June | 18 | 14 | 32 |
| 2017 May | 17 | 15 | 32 |
| 2017 April | 7 | 11 | 18 |
| 2017 March | 8 | 1 | 9 |
| 2017 February | 10 | 3 | 13 |
| 2017 January | 7 | 2 | 9 |
| 2016 December | 9 | 7 | 16 |
| 2016 November | 5 | 6 | 11 |
| 2016 October | 14 | 9 | 23 |
| 2016 September | 10 | 8 | 18 |
| 2016 August | 10 | 6 | 16 |
| 2016 July | 10 | 1 | 11 |
| 2016 June | 12 | 6 | 18 |
| 2016 May | 15 | 15 | 30 |
| 2016 April | 7 | 10 | 17 |
| 2016 March | 14 | 22 | 36 |
| 2016 February | 13 | 18 | 31 |
| 2016 January | 14 | 18 | 32 |
| 2015 December | 10 | 10 | 20 |
| 2015 November | 11 | 12 | 23 |
| 2015 October | 15 | 13 | 28 |
| 2015 September | 11 | 6 | 17 |
| 2015 August | 6 | 3 | 9 |
| 2015 July | 11 | 3 | 14 |
| 2015 June | 2 | 3 | 5 |
| 2015 May | 18 | 10 | 28 |
| 2015 April | 17 | 7 | 24 |
| 2015 March | 9 | 5 | 14 |
| 2015 February | 20 | 0 | 20 |
| 2015 January | 25 | 4 | 29 |
| 2014 December | 43 | 11 | 54 |
| 2014 November | 23 | 3 | 26 |
| 2014 October | 19 | 3 | 22 |
| 2014 September | 21 | 2 | 23 |
| 2014 August | 31 | 8 | 39 |
| 2014 July | 33 | 5 | 38 |
| 2014 June | 11 | 1 | 12 |
| 2014 May | 18 | 2 | 20 |
| 2014 April | 13 | 3 | 16 |
| 2014 March | 23 | 3 | 26 |
| 2014 February | 12 | 2 | 14 |
| 2014 January | 8 | 1 | 9 |
| 2013 December | 20 | 2 | 22 |
| 2013 November | 20 | 2 | 22 |
| 2013 October | 27 | 8 | 35 |
| 2013 September | 27 | 2 | 29 |
| 2013 August | 31 | 3 | 34 |
| 2013 July | 28 | 1 | 29 |
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