对于牛形弓左侧前循环大血管闭塞，经桡入路是否有优势？
采用“桡动脉入路优先”的方法在当代神经介入医师中越来越受欢迎。与介入心脏病学经验一致，经桡骨入路(TRA)在神经血管内手术中比传统经股入路(TFA)具有更高的安全性。这样的比较在急性缺血性脑卒中的血管内管理中尤为重要，因为这些患者经常服用抗血小板或抗凝药物，许多患者也接受静脉溶栓治疗。除了通常比较的安全性指标以外，导管到达到闭塞部位的时间同样重要。导管到位的时间和困难程度取决于主动脉弓和颈动脉解剖以及入路选择(即TRA与TFA)。
尽管比较急性缺血性脑卒中血栓切除术中TRA和TFA的研究报道了相似的手术时间和临床结果，但这些研究包括了主动脉弓和颈动脉解剖不均匀的患者队列。TRA被认为是II型或III型或牛主动脉弓(即无名动脉和左颈总动脉的共同起源)患者快速颅内通路的有利方法
Maud等人的研究强调了在牛主动脉弓和左前循环大血管闭塞的患者中，TRA比TFA在急性缺血性卒中取栓术中的优势。这项单中心的回顾性研究包括26例，在接受了TRA或TFA治疗的患者中平均分配(各13例)。当比较TRA和TFA时，作者报道了较短的穿刺时间(17.0±5.8 vs 35.4±20.5分钟;P=0.0001)、穿刺至再通(34.0±15.6 vs 58.1±34.6分钟;P=0.01)，总透视时间(13.8±9.4 vs 29.5±18.0分钟;P=0.03)。另外，2例接受TFA手术的患者需要转到TRA。
虽然研究中没有提到的其他因素，如颈动脉或锁骨下动脉的桡动脉袢和弯曲，也会影响TRA的容易程度，但牛足弓结构确实为左侧颈总动脉的选择提供了更容易的途径，且无需Simmons导管成型。
II型或III型主动脉弓结合牛弓形结构进一步强调了TRA在左颈总动脉和颈内动脉置管和维持结构稳定方面的优势，而TFA往往导致引导导管或引导鞘结构疝入升主动脉。
作者还发现TRA有更高的再通成功率(脑梗死溶栓≥2b;69.2%和53.8%;P=0.43)， 3个月预后优良率更高(改良Rankin Scale评分0-1分;38.5%和7.7%;P=0.06)，症状性脑出血发生率较低(0%对15.4%)。然而，这些结果应谨慎解释，因为TRA和TFA队列的基线特征是不同的。
具体而言，TFA队列的患者在就诊时国家卫生研究院卒中量表得分更高(15.4±5.8 vs 11.8±5.3)，从正常到医院的时间更长(381.9±448.6 vs 236.5 vs 275.8分钟)，发病前功能独立的比例更低(53.8% vs 84.6%)。TFA队列也有更多的串联闭塞(23%对7.7%)，这可能增加了病例的复杂性和手术时间。这些组间基线差异可能导致了TFA队列较差的临床结果。
实现尽可能短的时间成功再通仍然是大血管闭塞管理的目标。然而，从本研究中尚不清楚使用TRA获得的24分钟再通时间是否比TFA改善了临床结果，因为两个队列之间的基线特征不同。
目前还不清楚是否由于研究样本量小或病例复杂性的差异导致TRA实现的更快的血运重建。平衡基线患者特征的大型研究可以证明，在特定亚组中，TRA再通时间更快，但普通卒中结局量表(如改良的Rankin量表)可能不具备检测与时间改善相关的功能结局潜在改善的分辨率和敏感性。
最后，作者似乎对TRA感到满意，但他们的结果和节省的时间可能不能推广到其他缺乏TRA经验的中心和神经介入医生。
Transradial Versus Transfemoral Approach for Endovascular Thrombectomy of Left Anterior Circulation Stroke With Bovine Arch
Adoption of a “radial‐first” approach has become increasingly popular among contemporary neurointerventionalists. Congruent with interventional cardiology experiences, the transradial approach (TRA) in neuroendovascular procedures has demonstrated improved safety profile compared with the traditional transfemoral approach (TFA).1, 2, 3, 4 Such comparisons are particularly important in the endovascular management of acute ischemic stroke, as these patients are often taking antiplatelet or anticoagulant medications, with many also receiving intravenous thrombolysis. In addition to commonly compared safety metrics, catheter navigation time to the occlusion site is equally, if not more, important. Catheter navigation times and degree of difficulty are contingent on aortic arch and carotid artery anatomy as well as approach choice (ie, TRA versus TFA).5, 6 Although studies comparing TRA and TFA in acute ischemic stroke thrombectomies have reported comparable procedural times and clinical outcomes, these studies included patient cohorts with heterogeneous aortic arch and carotid artery anatomy.4, 6, 7, 8, 9 TRA has been proposed as a favorable approach for rapid intracranial access in patients with a type II or III or a bovine aortic arch (ie, common origin of innominate and left common carotid arteries).6
The study by Maud et al10 highlights the advantage of TRA over TFA in acute ischemic stroke thrombectomy for patients with a bovine aortic arch and left anterior circulation large‐vessel occlusion. This single‐center, retrospective study comprised such 26 cases, evenly split between those who underwent TRA or TFA (n=13 each). When comparing TRA versus TFA, the authors reported shorter puncture to microcatheter placement at clot interface (17.0±5.8 versus 35.4±20.5 minutes; P=0.0001), puncture to recanalization (34.0±15.6 versus 58.1±34.6 minutes; P=0.01), and total fluoroscopy (13.8±9.4 versus 29.5±18.0 minutes; P=0.03) times with TRA. In addition, 2 patients who underwent TFA required conversion to TRA. Although other factors not mentioned in the study, such as a radial loop and tortuosity of the carotid or subclavian arteries, affect the ease of TRA, bovine arch configuration certainly provides easier selection of the left common carotid artery without needing to form the Simmons catheter.5 A type II or III aortic arch in combination with a bovine arch configuration further underscores the advantage of TRA for catheterizing and maintaining a stable construct in the left common and internal carotid arteries, whereas TFA tends to result in herniation of a guide catheter or guiding sheath construct into the ascending aorta.
The authors also found TRA to have a higher rate of successful recanalization (Thrombolysis in Cerebral Infarction ≥2b; 69.2% versus 53.8%; P=0.43), higher rate of excellent outcome at 3 months (modified Rankin Scale score 0–1; 38.5% versus 7.7%; P=0.06), and lower rate of symptomatic intracerebral hemorrhage (0% versus 15.4%). However, these results should be interpreted with caution, as the baseline characteristics of the TRA and TFA cohorts were different. Specifically, patients in the TFA cohort had a higher National Institutes of Health Stroke Scale score at presentation (15.4±5.8 versus 11.8±5.3), longer known normal to hospital arrival time (381.9±448.6 versus 236.5 versus 275.8 minutes), and lower proportion of premorbid functional independence (53.8% versus 84.6%). The TFA cohort also had more tandem occlusions (23% versus 7.7%), which may have increased case complexity and procedural duration. These baseline between‐group differences likely contributed to the poorer clinical outcomes of the TFA cohort.
Achieving the shortest possible time to successful recanalization remains the goal of endovascular large‐vessel occlusion management. However, it is unclear from this study whether the 24 minutes gained in time to recanalization using TRA improved clinical outcomes compared with TFA, because of dissimilar baseline characteristics between the 2 cohorts. It is also unclear whether the faster revascularization achieved with TRA was a result of imprecision because of the small study sample size or differences in case complexity. Although a larger study that balances baseline patient characteristics could demonstrate faster times to recanalization with TRA in a particular subgroup, common stroke outcome scales (eg, modified Rankin Scale) may not have the resolution and sensitivity to detect potential improvements in functional outcome that correlate to the magnitude of time improvement. Finally, the authors appear comfortable with TRA, but their results and the potential time saved may not be generalizable to other centers and neurointerventionalists who have less TRA experience. Albeit, TRA for left anterior circulation pathology with a bovine arch removes one of the time‐ and experience‐limiting steps of needing to form the Simmons catheter to select the left common carotid artery.
Given considerable variability in vascular anatomy encountered during acute ischemic stroke thrombectomy, it may be challenging to compartmentalize each variant into a particular approach. Although left anterior circulation large‐vessel occlusions with a bovine arch could be easier to revascularize through TRA, such optimism can be hampered by a radial loop and carotid or subclavian artery tortuosity. Therefore, the approach choice for neuroendovascular interventions, such as thrombectomy, should be assessed on a case‐by‐case basis based on preprocedural noninvasive angiography and the practitioner's experience and comfort level with TRA and TFA.
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