Abstract 1122‐000059: Considering Transcarotid Access for Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta‐Analysis and Systematic Review
Authors: Zhong Allison J , Zhong Allison J , Kamal Haris , Uddin Anaz , Feldstein Eric , Shapiro Steven D , Chung Joon Yong , Ogarro Maziyah , Friedman Rebecca , Simmons Josh , Graifman Gillian , Kurian Christeena , Kaur Gurmeen , Mayer Stephan A , Chong Ji , Gandhi Chirag D , Al‐Mufti Fawaz 
Published: December 2021

Introduction
: Despite the success of mechanical thrombectomy in large vessel acute ischemic stroke, there remain cases where recanalization fails due to difficult anatomic access or peripheral arterial occlusive disease. In these cases, transbrachial or transcarotid access may be considered as alternatives to the transfemoral or increasingly popular transradial route. Of these approaches, the transcarotid route has not gained prominence due to safety concerns despite its prior routine use in angiography. In this study, we conducted a systematic review and meta‐analysis of the literature in order to better summate the data on transcarotid access.

Methods
: Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were used in order to perform a systematic review of articles published from 2010–2020 summarizing pre‐intervention characteristics of patients undergoing mechanical thrombectomy via transcarotid puncture. We performed a meta‐analysis focused on clinical outcomes, reperfusion times (in minutes), and overall complication rates of transcarotid access for mechanical thrombectomy. Pooled analyses were performed to examine predictors of complications and outcomes.

Results
: Six studies describing 72 patients, out of 80 attempts at carotid access (90% success rate), were included. Age ranged from the 5th to 9th decade (median 7.5). Initial National Institutes of Health Stroke Scale (NIHSS) score ranged from 4 to 28 (median 17). Direct carotid puncture was most often used as a rescue technique (86% of patients) secondary to failed femoral access. Successful recanalization was achieved in 85% of patients. Good 90‐day outcome (modified Rankin Scale ≤2) was achieved in 27% of patients. Median carotid puncture‐to‐reperfusion time was 32 minutes (CI = 24–40, p < 0.001). Cervical complications occurred at a rate of 23% (CI = 14– 35%, p < 0.001). Only one complication resulted in a fatal outcome and only one required an intervention (each 1.4%). Use of IV thrombolysis did not significantly predict better mTICI outcome. Complications were not predicted by use of IV thrombolysis or closure method. Carotid puncture as the primary access route was associated with significantly shorter procedure times and carotid puncture as a rescue route was associated with comparable procedure times to the classic femoral access route.

Conclusions
: Our results suggest that, despite current concerns about the use of transcarotid access, this technique can be considered a viable backup route in cases of failed transfemoral or transradial access. Though this method requires further research to better understand the variables that might play into clinical decision‐making for its use in acute stroke management, it is a promising area of study that could allow for thrombectomy in patients where it would otherwise be aborted.