急性缺血性脑卒中机械取栓术中经桡动脉与经股动脉入路的比较：最新系统回顾和荟萃分析。

IF 1.8 4区医学 Q3 CLINICAL NEUROLOGY

Clinical Neurology and Neurosurgery Pub Date : 2024-10-03 DOI:10.1016/j.clineuro.2024.108585

Amjad Almansi , Shahd Alqato , Mazen Negmeldin Aly Yassin , Lama Hossam Taher , Suhel.F. Batarseh , Abdulqadir J. Nashwan

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引用次数: 0

摘要

导言：最近，经桡动脉入路（TRA）用于急性缺血性卒中的机械血栓切除术因其潜在的优势（如减少入路部位并发症）而被提出作为一种替代方案。然而，与传统的经股动脉入路（TFA）相比，经桡动脉入路的安全性和有效性仍存在争议：我们在 PubMed、Scopus、Web of Science、Cochrane Library 和 Embase 上进行了全面搜索，搜索时间从开始到 2024 年 5 月 15 日。我们纳入了所有随机对照试验和观察性研究。主要结果是成功再通畅，即达到脑梗塞溶栓治疗（TICI）2b-3级。次要结果包括完全再通（TICI 3 级）、达到 TICI 2c 或更高、功能性结果（出院时和 90 天后的改良 Rankin 评分（mRS）、90 天后的 mRS 0-2、出院时的美国国立卫生研究院卒中量表（NIHSS）、住院时间（LOS））、程序效率（通路到灌注时间、首次再灌注、平均通路次数、交叉到替代方法）和安全性/存活结果（通路部位并发症、症状性颅内出血、院内和 90 天死亡率）。该研究已在 PROSPERO（CRD42023462293）上注册：荟萃分析包括13项研究，共涉及4759名患者。在成功再通畅方面，TRA 和 TFA 的差异无统计学意义（RR = 1.00 [95 % CI, 0.97-1.04]，P = 0.88）。分析还显示，各组之间在有利的功能性结果方面没有明显差异（RR = 0.88，[95 % CI，0.71-1.09]，P = 0.25），但存在明显的异质性（P = 0.008，I² = 71 %），排除 Phillips 等人 2020 年的研究（P = 0.58，I² = 0 %）后，异质性得到解决，TFA 优于 TRA（RR = 0.80，[95 % CI，0.70-0.92]，P = 0.002）。TFA 与 TRA 的交叉风险也显著降低（RR = 1.68，[95 % CI，0.99-2.86]，P = 0.05）。总体而言，TRA 的住院时间明显较短（MD = -1.49, 95 % CI [-2.93 to -0.05]，P = 0.04，I² = 75 %），但敏感性分析表明，平均差异不显著，仍有利于 TRA（MD = -0.59; 95 % CI: [-1.28 to -0.10]，P = 0.09，I² = 0 %）。在完全再通畅、TICI 2c 或更高、手术效率、功能结果、安全性和存活率方面，TRA 和 TFA 没有差异：我们更新的荟萃分析表明，TRA与TFA具有可比性，只是TFA在90天后达到mRS 0-2的患者比例更高，TFA的交叉率更低，而且TRA的住院时间（LOS）可能更短。由于纳入的研究都是观察性的，因此需要进一步的研究，尤其是随机研究来证实这些发现。

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Transradial versus transfemoral artery access in mechanical thrombectomy for acute ischemic stroke: An updated systematic review and meta-analysis

Introduction

Recently, transradial access (TRA) for mechanical thrombectomy in acute ischemic stroke has been proposed as an alternative due to potential advantages such as reduced access site complications. However, its safety and efficacy compared to the traditional transfemoral access (TFA) remain debated.

Methods

We conducted a comprehensive search on PubMed, Scopus, Web of Science, Cochrane Library, and Embase from inception to May 15, 2024. We included all randomized controlled trials and observational studies. The primary outcome was successful recanalization, defined as achieving Thrombolysis in Cerebral Infarction (TICI) grades 2b–3. Secondary outcomes included complete recanalization (TICI grade 3), achieving TICI 2c or higher, functional outcomes (modified Rankin Score (mRS) at discharge and 90 days, mRS 0–2 at 90 days, National Institutes of Health Stroke Scale (NIHSS) at discharge, Length of hospital stay (LOS)), procedural efficiency (access-to-perfusion time, first-pass reperfusion, mean number of passes, crossover to alternate approach), and safety/survival outcomes (access site complications, symptomatic intracranial hemorrhage, in-hospital and 90-day mortality). This study was registered in PROSPERO (CRD42023462293).

Results

The meta-analysis included 13 studies with a combined total of 4759 patients. No statistically significant difference was found between TRA and TFA for successful recanalization (RR = 1.00 [95 % CI, 0.97–1.04], P = 0.88). Analysis also showed no significant difference in favorable functional outcomes between groups (RR = 0.88, [95 % CI, 0.71–1.09], P = 0.25) with significant heterogeneity (P = 0.008, I² = 71 %), which was resolved by excluding the study of Phillips et al., 2020 (P = 0.58, I² = 0 %), then favoring TFA over TRA (RR = 0.80, [95 % CI, 0.70–0.92], P = 0.002). TFA also had a statistically significant lower risk of crossover to TRA (RR = 1.68, [95 % CI, 0.99–2.86], P = 0.05). Overall, TRA was associated with a significantly shorter length of stay (MD = −1.49, 95 % CI [-2.93 to −0.05], P = 0.04, I² = 75 %), though sensitivity analysis showed a non-significant mean difference still favoring TRA (MD = −0.59; 95 % CI: [-1.28 to −0.10], P = 0.09, I² = 0 %). There was no difference between TRA and TFA regarding complete recanalization, achieving TICI 2c or higher, procedural efficiency, functional outcomes, safety, and survival.

Conclusion

Our updated meta-analysis demonstrates that TRA is comparable to TFA, except for a higher proportion of patients achieving mRS 0–2 at 90 days with TFA, lower crossover rates with TFA, and possibly a shorter length of stay (LOS) with TRA. Further research, particularly randomized studies, is needed to confirm these findings due to the observational nature of included studies.

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来源期刊

Clinical Neurology and Neurosurgery 医学-临床神经学

CiteScore

3.70

自引率

5.30%

发文量

358

审稿时长

46 days

期刊介绍： Clinical Neurology and Neurosurgery is devoted to publishing papers and reports on the clinical aspects of neurology and neurosurgery. It is an international forum for papers of high scientific standard that are of interest to Neurologists and Neurosurgeons world-wide.