Dual Radial and Femoral Arterial Access for Mechanical Thrombectomy in Acute Middle Cerebral Artery Occlusion: A Case Report

Introduction

EVT is recognized as an effective option for acute ischemic stroke AIS. We present a case of an AIS patient with a challenging type III aortic arch variant successfully treated through a combined dual-access technique and the skillful adaptation of conventional devices, enabling timely superselection of the target vessel and subsequent thrombectomy. This case demonstrates the feasibility of a hybrid access strategy in challenging endovascular interventions, especially for patients with anatomical variations that complicate standard access routes.

Case Report

A 72-year-old woman was admitted with sudden-onset left-sided hemiparesis and altered mental status of 2 hours’ duration, without an apparent precipitating factor. The symptoms persisted and did not resolve with rest. She had a history of hypertension spanning over 20 years, which was poorly controlled despite ongoing oral antihypertensive therapy. Upon admission, she showed decreased responsiveness, with motor weakness in the left upper limb and lower limb graded as 1 on the Medical Research Council (mRC) scale. She was able to localize pain in her right limbs during physical examination and exhibited a positive Babinski sign on the left side, resulting in a National Institute of Health Stroke Scale (NIHSS) score of 22. Emergency CT scan of the brain revealed no hemorrhage, confirming acute cerebral infarction.

An intravenous line was established, and routine blood tests indicated no abnormalities. Following assessment by a neurologist, intravenous alteplase was administered without significant improvement, indicating large-vessel occlusion. An emergency cerebral angiography was performed under general anesthesia, with an 8-Fr femoral sheath placed in the right femoral artery using the Seldinger technique. Specifically, angiography showed that the patient’s aortic arch and brachiocephalic trunk formed an approximately 30-degree angle (Figure 1). The left common carotid artery angiography displayed both the left middle cerebral artery and left anterior cerebral artery, and the anterior communicating artery was absent due to anatomical variation (Figure 2). No collateral circulation was found from the left anterior cerebral artery, while the right posterior cerebral artery compensated for the right middle cerebral artery via the leptomeningeal branches.

Attempts to superselect the right common carotid artery via the femoral artery were unsuccessful, leading to a radial artery access attempt. Following unsuccessful attempts with a 6-Fr radial sheath, a 5-Fr single-bend snare was delivered via the radial artery to the aortic arch, merging with the 8-Fr MP2 (90 cm) from the femoral artery. Under roadmap guidance, successful capture of the 8-Fr MP2 was achieved. After gentle tensioning the snare and slight retraction, the guide catheter was smoothly advanced into the brachiocephalic trunk. We then slightly loosened the snare, maneuvered its loop toward the guide catheter’s tail, and re-tightened and slightly retracted it for further advancement into the deep segments of the brachiocephalic trunk. Finally, superselection of the right common carotid artery was achieved (Figure 3). An 8-Fr MP2 equipped with a 150 cm stiff guidewire was utilized, and imaging confirmed successful access with minimal trauma to the brachiocephalic trunk. Post-superselection angiography revealed occlusion at the right middle cerebral artery (Figure 4). Notably, there was an approximately 70-degree angulation at the origin of the right internal carotid artery, complicating catheter advancement (Figure 5).

Using the V-18 guidewire, a 6-Fr 125 cm intermediate catheter was advanced into the cavernous segment of the right internal carotid artery, allowing a 2.4-Fr 150 cm microcatheter to pass through the occluded segment. Hand-pushing angiography confirmed access to the true lumen. An Rvv-6-30 stent was deployed after a 7-minute pause employing the Stentriever With Intra-arterial Maneuver (SWIM) technique, 1 pass was ultimately successful, restoring patency of the right middle cerebral artery while the anterior cerebral artery remained non-visualized, showing only remnants of the A1 segment (Figure 6).

The right anterior cerebral artery was super-selected, an Rvv-4-20 stent was deployed, and thrombectomy was performed. Angiography demonstrated restored blood flow with faint visualization (Figure 7). Angiography of the left common carotid artery confirmed patency of the anterior communicating artery, supplying both anterior cerebral arteries (Figure 8). A postoperative cranial CT revealed no bleeding or contrast leakage. After surgery, the patient was prescribed aspirin (100 mg daily), clopidogrel (75 mg daily), and rosuvastatin calcium (10 mg daily). Acupuncture rehabilitation training commenced on the 3rd postoperative day, and a follow-up CT on the 14th day revealed no new infarction, although low signal intensity was noted near the Sylvian fissure, likely due to the right middle cerebral artery (MCA) occlusion (Figure 9). Upon discharge on the 16th day, the patient was conscious and speaking clearly, with equal and round pupils, and an mRS score of 1.

Discussion

AIS remains a leading cause of mortality and disability worldwide [1], with EVT recognized for its efficacy in restoring vascular patency [2–4]. The correlation between recanalization within the therapeutic window and patient recovery is well-established. However, unforeseen vascular variations can present significant obstacles, hindering the timely delivery of devices and compromising treatment efficacy. Successful thrombectomy is contingent upon timely access.

For patients with type III aortic arch, attention must be given to access route establishment, particularly in right-sided lesions. For patients with a type III aortic arch and significant lesions in the dominant vessels, we typically prefer utilizing the right radial artery for access. Conversely, if the origin of the dominant vertebral artery is low, access via the right femoral artery is favored [5]. Most cases of type III aortic arches can be successfully approached through the femoral artery using a 125 cm SIM2 catheter. However, in the present case, the brachiocephalic trunk formed a 30-degree angle with the ascending aortic arch, complicating and destabilizing the process of superselection. This made performing endovascular treatment exclusively through the femoral artery particularly challenging. While attempting to superselect the target artery via the femoral artery, the SIM2 successfully navigated into the right common carotid artery; however, the acute angle between the brachiocephalic trunk and the aortic arch hindered the maneuverability of the 8-F MP2 catheter into the right common carotid artery, prompting the consideration of a transradial approach (TRA) [6,7], which ultimately proved unsuccessful.

To overcome this, a snare inserted via the right radial access was used to grasp the guide catheter’s tip at the brachiocephalic trunk opening. The guide catheter was smoothly advanced into the brachiocephalic trunk by retraction of the snare device. This combined approach and techniques effectively overcame the limitations posed by guide catheter flexibility and the vascular anatomy variation, allowing successful superselection of the cervical artery.

Several studies indicate that TRA can serve as a valuable alternative for patients who are challenging to treat using the traditional transfemoral approach (TFA), particularly in those undergoing anticoagulation or antiplatelet therapy [8]. However, accessing the radial artery may present anatomical challenges. Instruments traversing from the radial artery, through the subclavian artery, or brachiocephalic trunk toward the aortic arch generally tend to direct inferiorly, contrary to the superior trajectory required for cerebral blood supply. This often necessitates the application of arch shaping techniques during TRA neurointerventional procedures [8]. Additionally, the smaller diameter of the radial artery restricts the utilization of various neurointerventional instruments, and there is currently a lack of dedicated instruments specifically designed for TRA applications [9–11].

While TRA is perceived to be more suitable for type II and III aortic arches, the tortuosity of the aortic arch can complicate the superselection of target cerebral vessels, potentially resulting in procedural failure [12–14]. In the present case, significant arterial tortuosity impeded successful access via the radial artery. Although the femoral artery is often preferred, anatomical complexities may necessitate a combined approach. Compared to the traditional single-access approach involving repeated attempts at selective catheterization of the culprit vessel with guidewire shaping, this straightforward combined-access and device strategy can conserve valuable time, potentially leading to more efficient and successful recanalization of the target lesion [15]. This case exemplifies the utility of a dual-access strategy, offering a potential solution for managing challenging access scenarios in endovascular treatment.

In the presented case, the “snare-grasp-fix-guide” technique successfully navigated a particularly challenging vascular anatomical variation. As this approach has not, to our knowledge, been previously reported, it offers a practical solution for similar complex cases and has value for clinical application. This example of accomplishing a complex task through simple device coordination suggests the potential for exploration in clinical practice and may inform the design of novel interventional devices.

We acknowledge that such unconventional techniques carry potential risks, such as vascular injury. To mitigate these risks during the “snare-grasp-fix-guide” maneuver, we rigorously controlled the amplitude of manipulation and utilized manual contrast injections to closely monitor vessel position.

Timely recanalization in acute ischemic stroke and promoting neuronal recovery are equally important. In addition to focusing on improved blood supply, post-thrombectomy adjunctive pharmacological therapies aimed at enhancing cellular metabolism and the microenvironment are crucial for optimizing patient outcomes and warrant comprehensive consideration [16].

Conclusions

In conclusion, this case report highlights the successful application of a dual radial and femoral arterial access approach for mechanical thrombectomy in a patient with acute middle cerebral artery occlusion complicated by a challenging type III aortic arch variant. The combined-access strategy proved critical in navigating the intricate vascular anatomy that hindered standard approaches, allowing for effective restoration of blood flow despite a complex clinical scenario. This case underscores the importance of adapting endovascular techniques to the unique anatomical challenges posed by individual patients, advocating for the consideration of hybrid access methods in endovascular interventions. The results from this intervention not only improved the patient’s neurological status but also demonstrate that such innovative approaches can be vital in enhancing outcomes in the treatment of acute ischemic stroke. Future studies with larger cohorts are needed to further evaluate the safety, efficacy, and broader applicability of dual access techniques in similar high-risk populations.