Miller School Leads in Transradial Access for Neurological Interventions
In 2018, Theresa Keith Horne of Pascagoula, Mississippi, had a dangerous aneurysm in a brain artery that was causing serious vision problems. She started seeing double and had a bloodshot and swollen, bulging left eye. After several specialists were unable to determine the problem, Horne sought care at Bascom Palmer Eye Institute – part of the University of Miami Miller School of Medicine – where neurosurgery was recommended due to the aneurysm’s position. Fortunately for Horne, Miller School neurosurgeons and interventional neurologists are leaders in an innovative access technique called the transradial approach.
After reviewing magnetic resonance imaging (MRI) scans, neurosurgeon Robert M. Starke, M.D. M.Sc., initially thought a craniotomy was needed. “But then I realized the transradial approach would allow us to treat Horne’s aneurysm effectively without brain surgery,” said Dr. Starke, who is professor of neurological surgery and radiology, co-director of endovascular neurosurgery at UM/Jackson Memorial Hospital, and director of neurovascular research.
To repair Horne’s challenging condition, Dr. Starke placed a stent that covered the wide base of her left internal carotid artery using a catheter inserted in the radial artery in her wrist rather than the widely used transfemoral approach, which provides access through the patient’s thigh.
Since that successful procedure, Horne’s vision has returned to normal with no further problems. “Dr. Starke is a brilliant doctor,” she said. “I am very grateful for the great care I received at the UM/Jackson Medical Center.”
For stroke patients, the transradial approach can enable neurologists to reach an arterial blockage more quickly – a potentially life-saving advantage, according to Dileep R. Yavagal, M.D., professor of clinical neurology and neurosurgery, and director of interventional neurology at UHealth Tower, the flagship hospital of the University of Miami Health System, and UM/Jackson Memorial Hospital. “Five years ago, I was lead author of a study showing that it was better to go through the wrist rather than attempting the transfemoral approach in stroke patients with unfavorable vascular anatomy,” said Dr. Yavagal.
“Other benefits include better patient comfort and safety,” said Eric Cecala Peterson, M.D., associate professor of neurological surgery and director of endovascular neurosurgery at UHealth Tower. “Our team’s research has shown the transradial approach is associated with fewer access site complications than the transfemoral technique.” In addition, the Miller School’s transradial experts are using this approach for diagnostic purposes.
Leading the way
Recognizing that the transradial approach has long been used by cardiologists, Dr. Peterson began looking at its potential for treating patients with blood vessel problems in the brain. In the past three years, Drs. Peterson, Starke and Yavagal have led several studies on neurological transradial approaches, spoken at national conferences and performed more than 5,000 diagnostic (endovascular angiography) and interventional procedures.
Several neurointerventional fellow trainees, including Brian Snelling, M.D., Diogo Haussen, M.D., Samir Sur, M.D., Priyank Khandelwal, M.D., Justin Caplan, M.D., Stephanie Chen, M.D., and Marie Brunet, M.D., made important contributions to the studies establishing this novel approach under the mentorship of the three faculty members.
“The transradial approach is a safe procedure with less pain and a shorter recovery period than transfemoral access procedures, which require a patient to lie flat for two to six hours,” said Dr. Starke. “That’s an issue for someone with back pain, respiratory issues or heart problems. With the transradial approach, patients can be walking around in 30 minutes and go home soon afterwards.”
While the transradial approach is not suited for all patients, about 90 percent of the team’s diagnostic angiography procedures and 75 percent of interventional procedures are now done through the wrist. “The innovation is not this technique,” said Dr. Peterson. “It’s realizing its value to patients and making a commitment.”
On the research side, the doctors have found that the transradial approach is equally or more effective for treating certain types of conditions, depending on the structure of the patient’s blood vessels. Their most recent collaborative study, “Transradial Versus Transfemoral Access for Anterior Circulation Mechanical Thrombectomy: Comparison of Technical and Clinical Outcomes,” was published in September in the Journal of Neurointerventional Surgery. The researchers looked at 51 patients, divided into two groups, and found the transradial approach had similar positive outcomes to the traditional transfemoral approach.
Dr. Starke, who delivered a keynote talk at the 2019 Society of Neurological Surgeons meeting in Miami, recently performed the first cerebral angiogram and treatment through the distal side of the radial artery at the top of the “anatomical snuffbox” on the wrist. “Our preliminary experience with dTRA for diagnostic cerebral angiography demonstrates excellent feasibility and safety in combination with relative efficiency,” said Dr. Starke, who was a co-author of the study, published in July in the Journal of Neurointerventional Surgery.
With their recognized leadership in the field, Drs. Starke, Peterson and Yavagal are frequently consulted by other specialists. “There is a significant learning curve for physicians, nurses and technicians,” said Dr. Yavagal. “But after gaining experience, the many benefits of the transradial approach become apparent to clinicians as well as patients.”