21 Percutaneous Radial Arterial Access for Thrombectomy
21.1 Case Description
21.1.1 Clinical Presentation
A 77-year-old male patient presented to the emergency department 45 minutes after sudden onset of vertigo and nausea followed by progressive decreased level of consciousness and coma. At the moment of the clinical examination, the patient was already intubated.
21.1.2 Imaging Workup and Investigations
Computed tomography angiography (CTA) of arch to vertex and noncontrast computed tomography (NCCT) of brain was immediately performed. CTA of the circle of Willis demonstrated occlusive thrombus in the proximal to midsegment basilar artery (Fig. 21.1). NCCT of the brain showed no signs of hemorrhage (Fig. 21.2).
CTA at the level of the aortic arch demonstrated a type III aortic arch (Fig. 21.3), as well as moderate tortuosity of the right vertebral artery origin (not demonstrated).
Fig. 21.1 CTA demonstrating complete midbasilar occlusion. 
Fig. 21.2 Noncontrast CT confirming absence of intracranial hemorrhage. 
Fig. 21.3 Arch CT angiography demonstrating a type III, which often heralds difficult femoral access.
21.1.3 Diagnosis
Acute basilar artery thrombosis.
21.1.4 Treatment
The patient was transferred immediately to the neuroangiography suite for an emergency mechanical thrombectomy. Given the difficult arch anatomy and vertebral tortuosity, a right radial access was used.
Materials
Radial access kit (Terumo Medical, Somerset, NJ).
Hydrophilic 10-cm 6-Fr vascular sheath (Glidesheath Slender Terumo Medical, Somerset, NJ).
5-Fr Berenstein catheter (Performa, Merit Medical, South Jordan, UT).
Soft-tipped Bentson guidewire (Cook Medical, Bloomington, IN).
0.035 Terumo guidewire (Terumo Medical, Somerset, NJ).
ACE 60 aspiration catheter (Penumbra, Alameda, CA).
Velocity microcatheter (Penumbra, Alameda, CA).
Transend microwire (Stryker Neurovascular, Fremont, CA).
Statseal, Biolife (Sarasota, Florida).
Safeguard Radial compression device (Merit Medical, South Jordan, UT).
Technique
Patency of the ulnopalmar arterial arcade was assessed using the modified, bedside Barbeau test. 1 Anesthesia was performed by administering a mixture of lidocaine 1% and 100 µg nitroglycerin into the subcutaneous tissues surrounding the radial artery under ultrasound guidance.
The radial artery was punctured at 45 degrees, approximately 1 to 2 cm proximal to the wrist crease, with a 22G short bevel micropuncture needle from a radial access kit.
A guidewire was advanced through the needle, with the wire position confirmed using ultrasound. A hydrophilic 10-cm 6-Fr vascular sheath was then advanced over the wire, without making a skin nick, by removing the guidewire and dilator.
A 20-mL syringe containing 2.5-mg verapamil, 2,000 international units unfractionated heparin, and 200 µg nitroglycerin was attached to the sheath sidearm with blood aspirated back into the syringe. This admixture of blood and fluid containing the three medications was then slowly instilled back through the sheath intra-arterially over 1 minute to augment local arterial vasodilation and minimize potential arterial spasm and/or thrombosis.
A 5-Fr Berenstein catheter was advanced through the radial sheath over a soft-tipped Bentson guidewire (Cook Medical, Bloomington, IN). The roadmap confirmed the moderate right vertebral artery tortuosity (Fig. 21.4).
The right vertebral artery origin was easily passed with a Terumo guidewire and the diagnostic catheter was placed in the distal V2 segment (Fig. 21.5).
Control angiography confirms the proximal basilar artery occlusion (Fig. 21.6). After an exchange maneuver, a coaxial system of an ACE 60 aspiration catheter and Velocity microcatheter was advanced over a Transend microwire up to the level of the basilar artery occlusion (Fig. 21.6).
After one pass of aspiration, there was complete recanalization of the basilar artery with no distal emboli (Fig. 21.7).
Fig. 21.4 Digital subtraction angiography demonstrating right vertebral artery tortuosity. 
Fig. 21.5 Right vertebral access with a Terumo guidewire and diagnostic catheter. 
Fig. 21.6 Digital subtraction angiography confirmation of unchanged basilar occlusion. 
Fig. 21.7 Complete basilar recanalization on digital subtraction angiography.
21.1.5 Postprocedural Care
Statseal and Safeguard Radial Compression Device were applied after which the arterial sheath was removed.
Patent hemostasis was confirmed by compressing the ulnar artery and assessing for radial artery patency using a pulse oximeter, followed by removal of the band after gradual deflation of the balloon tamponade.
21.1.6 Outcome
After extubation, the patient made a complete recovery (modified Rankin Scale: 0).
21.1.7 Background
Radial artery access has become an established approach for many cardiac interventionalists due to the significant decrease in access site complications and decreased mortality. 2 Since it was first introduced in 1989, 3 the improved time to patient mobilization postprocedure and low incidence of access site complications has made it particularly appealing, especially in situations where same-day discharge is preferable. 4 More recently, it has been adopted by many interventional radiology practices. 5 Where posterior fossa intervention is planned, access to the posterior circulation may be facilitated by this technique in the setting of challenging access from a traditional transfemoral arterial route, marked tortuosity of the vertebral arteries (including hostile origin access), or even considered an alternative to “routine” transfemoral route, either due to patient or operator preference. 6 Aortic arch anatomy may be challenging or unfamiliar to navigate from an upper extremity approach, particularly for left vertebral and left common carotid cannulation from right-sided access. This has delayed the adoption of radial artery access for standard diagnostic cerebral catheter angiography. However, difficult arch anatomy and severe abdominal aortic disease may represent a situation where upper extremity access is preferable over a conventional femoral approach.
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