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The Impact Of Access Site On Carotid Artery Stenting In Challenging Anatomy
Christopher Y. Chow, MD.
University of Miami, Miami, FL, USA.
OBJECTIVES: Variant aortic arch anatomy may increase the difficulty of performing carotid artery stenting (CAS). Radial artery access (RACAS) has been proposed as a means to circumvent limitations of transfemoral access (TFCAS). This study aims to determine if choice of access site affects the outcomes and complication rates after CAS.
METHODS: Data from patients who underwent CAS with either radial artery approach (RACAS) or transfemoral access (TFCAS) were obtained from the Vascular Quality Initiative (VQI) database during 2016-2023. Cases without an embolic protection device, transcarotid artery revascularizations, and patients suffering from carotid dissection, trauma, or fibromuscular dysplasia were excluded from the study. Patients with atherosclerotic carotid stenosis were included in the study and stratified into Type I versus Type II versus Type III aortic arch cohorts. The primary outcomes were postoperative stroke, transient ischemic attack (TIA), in-hospital death, myocardial infarction (MI), and access site complications. Secondary outcomes were total procedure time, fluoroscopy time, and length of hospital stay. Univariate and multivariate statistical analysis were performed.
RESULTS: 12,183 (94.75% TFCAS; 5.25% RACAS) patients were included in this analysis. RACAS was more frequently used in Type III aortic arch (8.88%) versus Type II (6.39%) and Type I (3.71%). Post-procedural stroke, TIA, MI, access site complications, and in-hospital death and hospital length of stay did not significantly differ depending on access site (p > 0.05). This finding persisted in subgroup analysis of aortic arch type. Although mean procedure time was greater in TFCAS (x̄= 67.45 minutes ± 0.38; 59.35 ± 1.15, p<0.001) across all aortic arch types, mean fluoroscopy time was significantly greater in RACAS (x̄= 23.74 minutes ± 0.71; 18.95 ± 0.15, p< 0.001). In type III aortic arches, RACAS resulted in a significant reduction of contrast volume (x̄= 99.35 mL ± 4.49; 108.73 ± 1.55, p= 0.037) but there were no other improvements in outcomes for patients undergoing RACAS.
CONCLUSIONS: Radial artery and femoral artery are similarly safe and efficacious access options for carotid artery stenting, regardless of aortic arch type. In comparison to TFCAS, RACAS may offer improvement in reduction of total procedural time and may lead to less contrast use in patients with type III aortic arches.
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