title: Difficult catheter access to the occluded vessel during endovascular treatment of acute ischemic stroke is associated with worse clinical outcome.
abstract: OBJECTIVE
  During endovascular procedures for acute ischemic stroke, catheter access to the occluded vessel may be technically difficult or impossible. The aim of this study was to access the impact of difficult catheter access to target the carotid artery on clinical outcome.
  
  
  METHODS
  Anterior circulation stroke patients undergoing transfemoral endovascular procedures where studied. Patients were divided into four groups according to time from groin puncture to target carotid catheterization quartiles. Patients in quartile 4 (Q4) were considered difficult carotid access. We defined several outcome measures: recanalisation (final Thrombolysis in Cerebral Infarction score ≥ 2a), time from groin puncture to recanalisation and favorable long term outcome (modified Rankin Scale score <3 at 3 months).
  
  
  RESULTS
  Of 130 patients studied, carotid catheterization was impossible in seven patients (5.1%). These patients had significantly lower rates of recanalization (14.3% vs 80.5%; p<0.01) and favorable outcome (0% vs 36%; p=0.038). Among patients with an accessible carotid artery(n=123), median time from groin puncture to carotid catheterization was 20 min (IQR 10). A negative correlation between time to carotid access and recanalization was observed (r=-0.31; p<0.01). Patients in Q4 (>30 min) had lower rates of recanalization (60.7% vs 82.4%; p=0.02) and a lower favorable outcome (13.6% vs 41.3%; p=0.04). A logistic regression adjusted by age showed that baseline National Institutes of Health Stroke Scale score (OR 0.8; 95% CI: 0.72 to 0.92 p<0.01) and having difficult access (OR 1.3; 95% CI 1.3 to 20.1 p=0.018) independently predicted worse long term outcome.
  
  
  CONCLUSIONS
  Difficult catheter access to target the carotid is common during acute endovascular treatment of stroke patients and is associated with a worse clinical outcome. If transfemoral access appears difficult, alternative access such as direct carotid puncture could be explored.
authors.affiliation: Unitat d'Ictus, Neurologia, Hospital Vall d'Hebron Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain. marcriboj@hotmail.com
authors.forename: Marc
authors.initials: M
authors.lastname: Ribo
authors.forename: Alan
authors.initials: A
authors.lastname: Flores
authors.forename: Marta
authors.initials: M
authors.lastname: Rubiera
authors.forename: Jorge
authors.initials: J
authors.lastname: Pagola
authors.forename: Nuno
authors.initials: N
authors.lastname: Mendonca
authors.forename: David
authors.initials: D
authors.lastname: Rodriguez-Luna
authors.forename: Soco
authors.initials: S
authors.lastname: Piñeiro
authors.forename: Pilar
authors.initials: P
authors.lastname: Meler
authors.forename: Jose
authors.initials: J
authors.lastname: Alvarez-Sabin
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Molina
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000175:diagnosis / Q000601:surgery*; D002339:Carotid Arteries / Q000601:surgery; D002406:Catheterization, Peripheral / Q000009:adverse effects / Q000379:methods*; D002561:Cerebrovascular Disorders / Q000175:diagnosis / Q000601:surgery*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005263:Femoral Artery / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D020521:Stroke / Q000175:diagnosis / Q000601:surgery*; D016896:Treatment Outcome