Trans-radial versus Trans-femoral Approach for Mechanical Thrombectomy in Contemporary Practice: Analysis from a Comprehensive Stroke Center

BACKGROUND AND PURPOSE: The trans-femoral approach (TFA) has historically been the standard approach for mechanical thrombectomy (MT) in acute ischemic strokes. Trans-radial approach (TRA) has gained popularity in recent years due to lower access-site complications and improved patient satisfaction. Data comparing procedural metrics, access conversion, and clinical outcomes between TRA and TFA remain limited. MATERIALS AND METHODS: We retrospectively analyzed data on patients undergoing MT from 2016 to 2024. Propensity score matching (PSM) was performed to adjust for baseline differences. Primary outcomes included access conversion, procedural time metrics, recanalization rates, and early functional outcomes. Cases requiring access conversion were analyzed for anatomical and technical factors. RESULTS: A total of 916 patients were identified and included (TFA: 674; TRA: 242). Following PSM, TRA was associated with higher rates of access conversion as compared to TFA (8.3% vs. 2.9%; p=0.017). However, there were no differences in procedure duration, recanalization grades, risk of postprocedural stroke or hemorrhagic conversion, as well as discharge NIHSS, or mRS (all p≥0.05). Also, the rate of access-site complications was similar in both groups (10% vs. 7.0%; p=0.20), although complications were milder in character in the TRA group. Procedures requiring conversion had longer puncture-to-intracranial access times (33.6 vs. 12.0 mins; p<0.001) and overall procedure duration (98.8 vs. 60.2 mins; p<0.001), but no difference in final recanalization, discharge NIHSS or mRS (all p≥0.05). TRA conversions were most commonly due to common carotid tortuosity and small-caliber or spastic radial arteries, whereas TFA conversions were driven by tortuous or variant aortic arch anatomy. Illustrative cases are presented. CONCLUSION: TRA is a safe and effective alternative to TFA for MT, with comparable safety and clinical outcomes, despite higher rates of access conversion. Individualized access selection based on patient anatomy remains essential to minimize procedural delays and maximize safety.