急性后循环大血管闭塞经桡动脉入路与经股动脉入路行血管内治疗的效果分析

Efficacy analysis of endovascular treatment through transradial approach and transfemoral approach in patients with acute ischemic stroke with large vessel occlusion in the posterior circulation

目的 比较急性后循环大血管闭塞患者经桡动脉入路(TRA)与经股动脉入路(TFA)行血管内治疗的安全性及效果。方法 回顾性连续纳入山东第二医科大学附属临沂市人民医院卒中中心2022年2月至2024年4月收治的129例后循环大血管闭塞行血管内治疗患者。收集患者基线及临床资料,包括年龄、性别、既往史(高血压病、糖尿病、高脂血症、心房颤动、冠心病、心肌梗死、脑梗死)、吸烟、入院血压、入院美国国立卫生研究院卒中量表(NIHSS)评分、发病前改良Rankin量表(mRS)评分、Alberta卒中项目早期CT评分(ASPECTS)、术前是否静脉溶栓、核心梗死区体积、低灌注区体积、血管病变部位、卒中病因、时间指标(发病至就诊时间、就诊至穿刺时间、穿刺至血管再通时间、发病至血管再通时间)、麻醉方式、血管内治疗首选方法、取栓次数及术中是否入路转换。临床资料包括术后90 d mRS评分、术后24 h内穿刺点并发症、术后72 h症状性颅内出血、术中末次造影改良脑梗死溶栓(mTICI)分级及住院天数。根据血管内治疗的最终入路方式将所有患者分为TRA组和TFA组,比较两组的基线资料和临床资料。结果 最终纳入后循环大血管闭塞行EVT患者129例,其中TRA组47例,TFA组82例。TRA组和TFA组在年龄、性别、既往史、吸烟、入院血压、入院NIHSS评分、发病前mRS评分、ASPECTS、术前静脉溶栓率、核心梗死区体积、低灌注区体积、血管病变部位、卒中病因、麻醉方式、血管内治疗首选方法、取栓次数、术中末次造影mTICI分级分布等方面差异均无统计学意义(均P>0.05);两组患者术后90 d良好预后率[53.2%(25/47)比48.8%(40/82),P=0.630]、术后90 d的mRS评分分布(P=0.991)、术后90 d病死率[27.7%(13/47)比28.0%(23/82),P=1.000]、术中末次造影良好再通(mTICI分级≥2b级)率[97.9%(46/47)比95.1%(78/82),P=0.436]、术后24 h穿刺点并发症发生率[4.3%(2/47)比12.2%(10/82),P=0.209]等方面差异均无统计学意义。与TFA组相比,TRA组的就诊至穿刺时间延长,两组间差异有统计学意义[122.00(95.00,153.00) min比105.00(80.25,118.00) min,Z=-2.937,P=0.030];TFA组较TRA组住院时间明显延长,两组间差异有统计学意义[6.00(4.95,7.05) d比7.00(6.95,8.88) d,Z=-2.573,P=0.010]。结论 后循环大血管闭塞患者TRA与TFA血管内治疗的安全性及效果无明显差异,且TRA患者住院天数更短。本研究结果仍需大型、前瞻性、随机对照临床试验验证。

Objective To compare the safety and efficacy of endovascular treatment(EVT)transradial approach and transfemoral approach in patients with acute ischemic stroke with large vessel occlusion in the posterior circulation.Methods Patients with acute ischemic stroke with large vessel occlusion in the posterior circulation admitted to the Stroke Center of Linyi People′s Hospital,Shandong Second Medical University from February 2022 to April 2024 were retrospectively recruited.The baseline and clinical data were collected,including age,sex,past medical history(hypertension,diabetes mellitus,hyperlipidemia,atrial fibrillation,coronary artery disease,myocardial infarction and stroke),smoking,blood pressure at admission,National Institutes of Health stroke scale(NIHSS)score at admission,modified Rankin scale(mRS)score before the onset of stroke,Alberta stroke program early CT score(ASPECTS),whether intravenous thrombolysis was performed,volume of core infarct zone,volume of hypoperfused zone,occlusion location,etiology of stroke,time indexes(including time from onset to door,time from door to arterial puncture,arterial puncture to recanalization,and time from onset to revascularization),anesthesia modality,EVT first-line strategy,number of passes and whether with vascular access conversion.Clinical data included 90-day postoperative mRS scores,postoperative puncture site complications in 24 hours,symptomatic intracranial hemorrhage at 72 hours postoperatively,modified thrombolysis in cerebral infarction(mTICI)grade at the last angiography introperative and length of stay.The groups were categorized into transradial(TRA)and transfemoral(TFA)groups according to the final access route for EVT.The baseline and clinical data of the two groups were compared.Results A total of 129 patients underwent EVT with acute ischemic stroke with large vessel occlusion in the posterior circulation were finally included,including 47 patients in TRA group and 82 patients in TFA group.The differences about sex,age,past medical history,smoking,blood pressure at admission,NIHSS score at admission,mRS score before the onset of the stroke,ASPECTS,whether intravenous thrombolysis was performed,volume of core infarct zone,volume of hypoperfused zone,occlusion location,etiology of stroke,anesthesia modality,EVT first-line strategy,number of passes,mTICI grade at the last angiography introperative and other aspects were not statistically significant(all P>0.05).The good prognosis rate at 90 d after surgery(53.2%[25/47]vs.48.8%[40/82],P=0.630),distribution of mRS scores at 90 d postoperatively(P=0.991),all-cause mortality at 90 days after surgery(27.7%[13/47]vs.28.0%[23/82],P=1.000),rate of good recanalization(mTICI grade≥2b)on intraoperative last angiogram(97.9%[46/47]vs.95.1%[78/82],P=0.436),rate of complication of puncture site(4.3%[2/47]vs.12.2%[10/82],P=0.209)between the two groups were not statistically significant.The time from door to arterial puncture was significantly longer in the TRA group than in the TFA group,and the difference between the two groups was statistically significant(122.00[95.00,153.00]min vs.105.00[80.25,118.00]min,Z=-2.937,P=0.03);average length of stay in the TFA group was significantly longer than that of the TRA group,and the difference between the two groups was statistically significant(6.00[4.95,7.05]d vs.7.00[6.95,8.88]d,Z=-2.573,P=0.010).Conclusions Patients who underwent EVT via radial or femoral artery approach with acute ischemic stroke with large vessel occlusion in the posterior circulation had similar safety and efficacy,and the number of days of hospitalization was shorter via the TRA.However,more large prospective randomized controlled clinical trials are needed to validate the results of this study.