Efficacy and safety of trans-carotid approach for mechanical thrombectomy in acute ischemic stroke: a multicenter two-arm case series with systematic review and meta-analysis

Direct carotid puncture (DCP) is a rescue technique when recanalization using peripheral access sites is challenging. It is not frequently employed due to concerns with complications or operator unfamiliarity. The safety and efficacy of the transcarotid approach have yet to be sufficiently characterized. A multicenter, retrospective study comparing mechanical thrombectomy outcomes for large vessel occlusion patients using DCP versus medical management after failed peripheral access attempts. Univariate analyses were performed to evaluate the data. We combined the DCP group data from our cases with the existing literature to conduct a single-arm meta-analysis. We utilized logistic and linear regression analyses on individual patient data to identify factors predicting outcomes such as mortality and complications. DCP patients had a longer last known well (<i>p</i> = 0.027) with no statistically significant difference in follow-up modified Rankin scale (mRS) or National Institutes of Health Stroke Scale (NIHSS). The meta-analysis consisted of nine studies, including our retrospective cohort, with a total of 107 patients. DCP achieved successful recanalization in 86% of cases, with a 31% complication rate, primarily due to cervical hematomas. Ninety-day mortality was 37%. 24% of patients attained functional independence (mRS 0–2). Factors associated with higher mortality included advanced age, higher NIHSS scores, and lower ASPECTS scores. Recanalization was associated with improved outcomes. DCP for mechanical thrombectomy is a valuable rescue strategy, offering excellent reperfusion outcomes with acceptable complication rates. Functional independence and independent ambulation at 90 days were comparable to the outcomes reported in recent landmark trials on large-core thrombectomy.

直接颈动脉穿刺术（Direct Carotid Puncture, DCP）是当外周入路路径下的血管再通操作难度较大时采用的抢救性技术。由于存在并发症风险担忧以及术者操作经验不足，该技术的临床应用并不普及。经颈动脉入路的安全性与有效性尚未得到充分阐明。本研究为一项多中心回顾性研究，对比了大血管闭塞患者在外周入路操作失败后，采用DCP行机械取栓术与药物保守治疗的预后结局。研究对数据集进行了单因素分析。我们将本中心病例的DCP组数据与已发表文献数据整合，开展了单臂荟萃分析。我们针对患者个体数据开展了logistic回归与线性回归分析，以筛选可预测患者死亡、并发症等结局的相关危险因素。接受DCP治疗的患者，其最后已知正常时间更长（p=0.027），但随访时的改良Rankin量表（modified Rankin Scale, mRS）评分与美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale, NIHSS）评分均无统计学显著性差异。本次荟萃分析共纳入9项研究（含本中心的回顾性队列研究），累计纳入107例患者。DCP的血管再通成功率达86%，并发症发生率为31%，其中以颈部血肿最为常见。患者90天死亡率为37%，24%的患者实现了功能独立（mRS评分0~2分）。与更高死亡风险相关的因素包括高龄、基线NIHSS评分更高以及阿尔伯塔卒中计划早期CT评分（Alberta Stroke Program Early CT Score, ASPECTS）更低。成功血管再通与更佳的临床预后相关。用于机械取栓的DCP是一项极具价值的抢救性策略，可获得优异的血管再灌注结局，且并发症发生率处于可接受范围。患者90天时的功能独立能力与独立行走能力，与近期针对大核心梗死卒中取栓的标志性临床试验所报道的结局相当。