Gurmeen Kaur, MBBS, and Kat Dakay, DO
@kaurgurmeen; @katarinadakay

Conventional cerebral angiography has been trans-femoral and has a consistent 2-3% rate of femoral arterial complications, including pseudo-aneurysms, retroperitoneal hematomas, and access site bleeding.

Interventional cardiology has promoted and adopted the trans-radial approach, significantly reducing access site complications. Large-scale cardiology trials (RIVAL, RIFLE) have even demonstrated the increased safety of percutaneous coronary interventions using the radial approach.1

Over the last two years, the use of the radial approach for neuro-interventional procedures has dramatically increased. Multiple studies have demonstrated improved patient experience and a reduction in access site complications using the radial approach. Another major advancement has been the use of distal radial access.2 The distal radial artery, located in the anatomical snuff box, is distal to the origin of the superficial palmer branch, which supplies numerous palmar collaterals to the deep palmar arch. This further reduces the incidence of ischemic hand from radial artery occlusion and is more ergonomic for the operators.3 Additionally, in a patient undergoing a diagnostic angiogram as part of treatment planning, the proximal radial artery, which has a bigger caliber, can be preserved for the interventional procedure.

Radial access is not without challenges. One challenge has been that most neuro-catheters are not hydrophilic and not designed for radial access. There is also a learning curve involved in gaining access, positioning the patient optimally, and using the Simmons catheter for accessing the cerebral vessels. Additionally, the right radial approach can be difficult if the primary vessel of interest is the left vertebral artery.

Overall, the ‘radial first’ approach improves patient comfort, lowers rates of access site complications, and shortens recovery times.

References:

1.           Snelling BM, Sur S, Shah SS, Khandelwal P, Caplan J, Haniff R, et al. Transradial cerebral angiography: Techniques and outcomes. J Neurointerv Surg. 2018;10:874-881

2.           Haussen DC, Nogueira RG, DeSousa KG, Pafford RN, Janjua N, Ramdas KN, et al. Transradial access in acute ischemic stroke intervention. J Neurointerv Surg. 2016;8:247-250

3.           Patel P, Majmundar N, Bach I, Dodson V, Al-Mufti F, Tomycz L, et al. Distal transradial access in the anatomic snuffbox for diagnostic cerebral angiography. AJNR Am J Neuroradiol. 2019;40:1526-1528