Transradial carotid artery stenting: A comprehensive registry analysis and comparative evaluation of access routes for improved outcomes

Introduction. Carotid artery stenting via the radial route is being investigated as a potential strategy to mitigate access-related bleeding in carotid artery interventions. Ongoing trials and procedural initiatives seek to enhance the overall efficacy of these interventions. The utilization of transradial access (TRA) for Carotid Artery Stenting (CAS) holds promise in reducing bleeding incidents compared to the traditional transfemoral approach (TFA). Methods. Clinical trials are currently examining the comparative benefits of carotid revascularization versus exclusive reliance on best medical therapy for asymptomatic patients. Our interventions primarily targeted symptomatic or high-grade carotid stenosis. A comprehensive five-year registry analysis of carotid artery stenting was conducted, encompassing a comparison of outcomes between transfemoral and trans-radial interventions, as well as inter-operator and patient subset analyses. Results. Over the five-year period from 2018 to 2022, a total of 573 CAS procedures were performed. The majority of patients (77%, or 442) underwent TRA, with a predominant male representation (68%). Four operators exhibited varying proportions of TRA/TFA utilization, and the choice of approach was at the operator's discretion. The interventions predominantly involved the use of embolic protection (EP). The primary outcome measure, encompassing major events such as stroke, death, or bleeding, occurred more frequently in the TFA group, with rates of 6.2% (8/131) compared to 2.5% (11/442) in the TRA group, resulting in an overall incidence of 3.3% major adverse events in the entire registry. Notably, the majority of major adverse events were attributed to bleeding, with rates of 3.8% in the TFA group and 1.6% in the TRA group. Conclusions. While our findings suggest superior outcomes for TRA CAS compared to TFA CAS, it is important to acknowledge the presence of real and significant confounding factors associated with operator variability and the absence of randomization between groups. Consequently, statistical comparisons are deemed neither fair nor scientifically robust in this context. This observational analysis of registry data serves as a hypothesis-generating exercise, underscoring the necessity for further investigations into the impact of access route on CAS outcomes.