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

Objectives: 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. Methods: 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. Results: DCP patients had a longer last known well (p = 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. Conclusion: 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.