Instead of accessing the brain via the femoral artery by going through the groin area, Drs. Mayshan and Mahan Ghiassi often go through the patient’s wrist to perform procedures, such as the removal of blood clots.
Advancements in the tools that are used to perform these kinds of surgeries have made the radial approach a more viable option in recent years as devices have become smaller and more streamlined, Mayshan Ghiassi said. The technique uses the radial artery, which is located in the forearm and connects to the brain.
“We’re able to use a smaller catheter and that means less injury to the blood vessels themselves as we’re going in and out,” he said.
With a lower profile system, “things are a little bit easier,” he added. “We can deliver devices further out in the brain and treat things that in the past we would not necessarily treat or treat using traditional open surgery where you have to do a craniotomy — open the skull and actually go into the brain. Now, we can get away with a small, little hole in the wrist and take care of those problems.”
The wrist approach has been used more extensively in cardiology but is gaining momentum in the world of neurosurgery for transradial cerebral angiography. It’s also used for diagnostic tests (angiograms).
This is “applying a technique that the cardiologists are using and then taking that technique and modifying it for our needs,” said Dr. Justin Fraser, a Lexington neurosurgeon.
Fraser uses the technique at the University of Kentucky Albert B. Chandler Hospital, where it’s being introduced in a methodical manner as staffers get trained.
“We kind of roll it out with some of the less complex cases first and then advance to more complex cases,” said Fraser, director of cerebrovascular neurosurgery for UK HealthCare and surgical director of UK’s comprehensive stroke center.
The goals, Fraser said, include reducing complications and their severity. “Whereas transfemoral approaches can involve complications that can be life-threatening, it would be pretty rare for something like that to happen” with the radial approach, he said.
More study of the radial technique as a neurointervention is expected. But “I think it’s going to likely transition to being the dominant approach,” Fraser said. “That doesn’t mean every patient can get it, but I think it’s one of those things that it’ll be the go-to for most cases.”
Mayshan Ghiassi, who’s based at Norton Brownsboro Hospital, said he started using the radial approach about five years ago, before he came to Louisville. “Recently, in the last year and a half, I’ve transitioned to a majority radial,” he said.
He has performed surgery, using the technique, with his brother and while solo, he said.
The radial approach allows patients to be “more comfortable” and there are less issues with complications “as far as bleeding complications go,” he said.
Another plus is being able to forgo general anesthesia, although that’s not limited to the radial approach, he said.
“The more we advance with our ability to treat brain aneurysms and strokes, the less we’re utilizing general anesthesia, just because of the risks that are associated with general anesthesia,” he said. “We try to avoid general anesthesia, especially in a situation where the patient is having a stroke, where the brain is being starved of blood, and if you have a rapid decrease in your blood pressure that could lead to a larger stroke.”
With the patient awake during the radial approach, “we’re able to monitor their neurologic status real-time as opposed to having to wait for somebody to come out from under anesthesia,” he said. So “we’re talking to them. We’re asking them to do various tasks. Sometimes, we do give patients some anti-anxiety medicine if they’re anxious. But this is not a very painful procedure, so overall, it’s fairly well tolerated.”
There are other convenience factors as well. For example, Fraser noted that with the radial approach to vascular brain procedures, a patient typically recovers for a much shorter time, and they don’t have to lie flat since the radial technique doesn’t require “no bending at the waist” as the femoral approach does.
A patient might have to lie flat for as much as six to eight hours with the femoral approach, so that can be a real concern for patients, such as older individuals with back issues, Mayshan Ghiassi said.
A Paducah massage therapist, Tina Terrell, has undergone aneurysm treatment, using both approaches at different times.
Terrell, 54, had a ruptured aneurysm repaired, using the femoral approach, in 2012 in Tennessee. At that time, doctors found five small, unruptured aneurysms, and Terrell was instructed to receive annual monitoring.
She was eventually referred to the Ghiassi brothers and underwent surgery, using the radial approach, for two of her aneurysms.
Terrell said she liked being able to stay awake with the radial by Mayshan Ghiassi.
“I actually felt safer with that because I had the doctors talking to me,” she said. “And also the fact that if something did go wrong, and maybe I was having a stroke or something, they would actually be able to know that, with me being awake, because they were talking to me.”
After the radial, she was alert, had no major headaches, could eat right away and was discharged from the hospital the next day, she said.
The main downside to the radial approach was having a hematoma (bruising) on the wrist that kept Terrell from working for about a week, she said, because she could not apply the pressure needed to do deep massages for clients.
“After the inflammation and everything healed up, I haven’t had any problems with my wrist at all,” she said. “There’s been no problems whatsoever.”
But radial approaches aren’t always appropriate. For example, the patient might have had trouble with hand circulation in the past, Fraser said.
Despite having a good experience with minimally invasive radial angiography, Terrell said she might have to have her head cut open in the future to repair an aneurysm that’s “pretty deep.”
Meanwhile, she’s grateful for the care that she’s received, so far. People faced with these kind of medical issues “want someone that really cares and somebody that really listens” to their concerns, she said.