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Radial vs. Femoral Approach for Treatment of Acute Hemorrhagic and Ischemic Stroke Patients, Part 2
After an extensive survey of the available literature, we are unable to locate additional peer-reviewed works that fit the project criteria to add to the project spreadsheet. Even within the most recent US literature, the transradial approach to treat acute ischemic strokes and hemorrhagic strokes is undertaken only when the transfemoral approach is unviable, e.g., due to blockage. We find no applicable studies expressly performed in Western or Central Europe, Russia, the Middle-East, or Africa. While it is conceivable that one or more studies in those regions do exist and escape our discovery due to language barriers, we find that exceedingly unlikely for reasons we have detailed below in an extensive research methodology.
Research Criteria
Having found PubMed to be insufficient to our needs, we utilized Google's Scholar database for the current round of research. This has the added advantage of enabling us to quickly determine a chain of article citations in both directions, enabling us to quickly search for follow-up studies, literature reviews, and patient surveys connected to a given paper. We focused on the following criteria:
- Papers focused on patient preference regarding transradial vs. transfemoral approach in cases of acute hemorrhagic or ischemic stroke, including patient concerns and benefits, or
- Papers discussing the medical benefits of the transradial approach, including hospitalization times, surgery times, outcomes, etc; and which are
- Preferably published in neurovascular journals rather than cardiac and with titles that indicate that neurovascular surgery rather than, for example, placing a stent in a coronary artery, is the subject;
- And published by teams in Western Europe, Russia, Central Europe, the Middle East, and Africa.
Initial Methodology
Our initial sweep, in which we focused on papers only discussing the transradial approach for the two types of stroke, gave us 1,260 results. Adding "transfemoral" to our criteria cut the number of results in half. There were many false positives in which it was clear from the title or the journal name that the paper was not suited for our purpose. We conducted a quick survey of the first 20 or so results to get a sense of how many other false positives we had pulled, immediately discarding five as completely irrelevant.
- 12 were of US origin or indeterminate but likely in the US,
- 1 could not be accessed due to a paywall, and
- 2 were from East Asia (Korea and China, specifically).
Second Approach: Narrowing Focus to Specific Regions
As this did not bode well for finding a sufficient number of peer-reviewed studies in the allotted time frame, we next attempted to restrict our search results to those with mentions of the specific regions and countries given in the research criteria:
- "Russia" resulted in 33 articles, most of which were not based on research conducted within Russia itself or else which were from cardiovascular journals. Only one partially fit the requested criteria:
- "The use of transradial access for embolization of the basilar artery aneurysm" combines the case study of a single patient with a literature review; however the focus is on stenting, with the transradial approach mentioned only in passing.
- "Europe" provided 132 articles to survey. We did not keep a close count, but the overwhelming majority were focused on transradial approaches in cardiology and were completely irrelevant to this brief. Those which did focus on treatment for strokes did not reference either patient preferences or compare outcomes between the two approaches.
- Our attempts to search for individual nations--specifically, the United Kingdom, France, and Germany--met with failure for the same reasons.
Due to our approaching deadline, we did not continue in our attempts with the Middle-east and Africa; simply put, there are too many nations in those regions to properly narrow down our criteria and survey the results, and our results thus far indicated that this method was likely a dead end.
We should note that it is very common for papers published in medical journals to omit their country of origin, let alone their region, as irrelevant to their study. While certain areas of study are geographically bound--for example, the study of a localized disease or the socioeconomic impact of a healthcare policy--it appears that the approach to treating acute hemorrhagic or ischemic stroke is not among them.
Third Approach: Understanding the Field
At this point, we nominally expand the research criteria in order to provide useful findings which, though not precisely requested, would nevertheless be pertinent and insightful. However, this largely resulted in the rediscovery of the sources which our colleague had already collected in their previous brief. Consequently, we set out to understand why examples that fit, or are at least pertinent to, the criteria and purpose of this brief are so scarce.
A literature review published in 2020 by Mohammad R. Ghani, et al., provided the critical insight into why comparisons between transradial and transfemoral approaches to neurovascular procedures are so rare, even today:
- "The brachial, radial, transcervical, and direct carotid arteries are mostly used when access via the femoral artery is not possible. Neuroendovascular procedures are traditionally performed using the common transfemoral approach because of the size and length of endovascular equipment."
- In general, 71% of patients prefer transradial access over transfemoral due to lower bleeding risk, lower pain, and the inability to walk immediately after a transfemoral procedure.
However, neither the above literature review nor our own search uncovered surveys specifically for stroke patients regarding either their preferences or satisfaction with regard to the approach their surgeon took to reach and treat the stroke site. Regarding the former, it would seem likely that the very nature of a stroke, with its sudden onset and debilitating symptoms, removes the patient's preferences as a factor in determining a course of treatment. Patient satisfaction with one over the other after the procedure would likewise be difficult to gauge, given the long-term and often debilitating aftereffects of a stroke.
Several of the sources used by the above literature review were already covered in our colleague's work. Among those which have not already been added to the project spreadsheet, the three cited in Table 2: "Summary of the advantages and disadvantages of transfemoral access and transradial access in acute ischemic stroke," are the following:
- "Transradial Approach for Coronary Angiography and Interventions: Results of the First International Transradial Practice Survey" (2010), which does not refer to the treatment of strokes specifically, though it has the advantage of surveying "1,107 interventional cardiologists in 75 countries." However, apart from the international aspect, it appears tangential to the purposes of this brief.
- "Left transradial access for cerebral angiography" (2019), which does not make any direct comparisons to transfemoral access, only concluding, "Left transradial access in diagnostic and interventional cerebral angiography is a technically feasible, safe, and an effective alternative when indicated..."
- "Transradial stenting of the cervical internal carotid artery: technical case report" (2003), which is both too early and off-topic for our purposes.
The literature review by Ghani, et al., draws the above sources together into an advantage/disadvantage chart for both forms of access in acute ischemic stroke:
However, even here, the authors are clearly interpreting disparate data through the lens of their experience. That they are forced to do so, rather than provide A/B test results from existing studies on the clinical benefits of one approach over another in the treatment of stroke victims, proves beyond a reasonable doubt that no such study has yet been undertaken.
Conclusion
While patients, in general, overwhelmingly prefer the transradial approach for cardiovascular and neurovascular procedures, for reasons explained above, we are not convinced that such preferences translate into the victims of acute ischemic and hemorrhagic strokes. At the present time, the focus in the medical community is on demonstrating that transradial access to treat strokes is at least as safe as the transfemoral approach, but as of the present day, the transradial approach is still used only when it is impossible to access the injury site through the transfemoral, which remains the standard.