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Introduction Transradial access (TRA) has become increasingly utilized among neurointerventionalists. There is evidence of reduced complications and higher patient satisfaction compared to transfemoral access (TFA), but more data directly comparing the safety and efficacy of the two approaches is needed. To assess the proportion of technical success and complications with TRA versus TFA in patients who underwent neuroendovascular diagnostic and therapeutic procedures. Methods PRISMA guidelines were used to conduct a systematic review of the literature with PubMed/Medline, Scopus, Embase, and Cochrane databases up to February 2023. Randomized clinical trials (RCT) and observational studies that compared TRA and TFA were included. Studies reporting results of patients who underwent diagnostic angiograms, endovascular management of acute stroke, aneurysm repair, and carotid or vertebral stenting were included. Our primary outcome was technical success, defined as successful arterial access and completion of the intended procedure without crossover. Secondary safety outcomes were rate of complications including access site and non‐access site related, and other efficacy measures such as procedure duration, fluoroscopy time, and radiation exposure. Random effects model was used to perform a meta‐analysis. The Mantel‐Haenszel method was used to calculate risk ratio (RR) and 95% confidence intervals (CI) for each outcome. Heterogeneity was evaluated using I2 and considered high if over 70%. Results Twenty‐nine studies comprising 14,523 patients met inclusion criteria. TRA was attempted in 5,865 (40.38%) patients and TFA in 8,658 (59.62%). Baseline characteristics were similar between groups. The rate of technical success was 95.46% (95% CI: 93.59 – 96.81; p < 0.01) in the TRA group compared with 98.43% (95% CI: 97.60 – 98.97; p = 0.02) in the TFA group. Patients who underwent a diagnostic or therapeutic angiogram via TRA had a slightly lower chance of achieving technical success (RR = 0.98; 95% CI: 0.96 – 0.99; p < 0.01) compared to TFA, with substantial heterogeneity (I2 = 68%). Major access site complications were non‐significantly lower in the TRA group (RR = 0.64; 95% CI: 0.29 – 1.41; p = 0.81) with null heterogenicity (I2 = 0%) between groups. Minor access site complications were significantly lower in the TRA group (RR = 0.43; 95% CI 0.28 – 0.67; p < 0.01), with moderate heterogeneity (I2 = 57%). Non‐access site related complications (including mortality) were lower in the TRA group (RR = 0.69; 95% CI 0.51 – 0.94; p = 0.14) with low heterogeneity (I2 = 26%) between groups; for this outcome, the TRA approach shows a protective but not statistically significant result. Conclusion Our study suggests TRA is feasible and safe for diagnostic and therapeutic neuroendovascular procedures with low certainty of evidence. Minor complications were lower in the TRA group. RCTs directly comparing TRA vs TFA for these procedures are needed to confirm these results.

Background Mechanical thrombectomy (MT) failure occurs in ≈10% to 20% of MTs. Among the common causes of failed MT is residual underlying intracranial stenosis (ICAS), typically attributable to atherosclerotic disease. ICAS large‐vessel occlusion (ICAS‐LVO) remains poorly understood, and management of ICAS‐LVO is unclear. The RESCUE‐ICAS (Registry of Emergent Large Vessel Occlusion Due to Intracranial Stenosis) aims at providing better understanding of the prevalence of ICAS‐LVO, and the overall safety and efficacy of various rescue therapies. Methods RESCUE‐ICAS is a multicenter, international, prospective registry that is currently enrolling patients with ICAS‐LVO who underwent MT. All sites are required to report monthly MT cases that meet inclusion criteria. The decision of whether to use rescue therapy is up to the interventionist. Results We will collect patients’ demographic, clinical, and radiographic data at baseline. Also, we will capture variables related to the MT procedure and rescue therapy (if performed), and postprocedural clinical and imaging variables. Outcomes include the rate of successful recanalization, defined by modified Thrombolysis in Cerebral Infarction score of ≥2b, the rate of symptomatic intracranial hemorrhage, the 90‐day modified Rankin scale score, and mortality. Conclusions No strong evidence is currently available to support an optimal treatment strategy for patients with ICAS‐LVO undergoing MT. RESCUE‐ICAS is a prospective cohort study that will provide important data to help design randomized controlled trials.

Background In cases of failed recanalization despite modern mechanical thrombectomy (MT) techniques, intracranial rescue stenting (RS) may be beneficial. However, outcomes and complications of RS relative to the natural history of ongoing emergent large vessel occlusion are unknown. To evaluate whether RS for ongoing emergent large vessel occlusion after failed MT achieves superior outcomes to the natural history of persistent emergent large vessel occlusion. Methods Patients from the Stroke Thrombectomy and Aneurysm Registry who underwent RS after failed MT from 2014 to 2019 were analyzed. For outcome comparisons, patients were screened for inclusion/exclusion criteria of 3 major randomized, controlled MT trials. Results Over 5 years, 2827 patients underwent thrombectomy, of which 120 required RS for failed revascularization. RS resulted in reperfusion (Thrombolysis in Cerebral Infarction≥2B) in 85.8%. Good 90‐day clinical outcomes (modified Rankin scale 0–2) were achieved in 33.9% of patients. Inclusion/exclusion criteria was met in 50 patients for MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), 64 patients for ESCAPE (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke), and 45 patients for DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake‐Up and Late Presenting Strokes Undergoing Neurointervention). Of patients meeting trial criteria, 40.8% of the RS cohort achieved modified Rankin scale 0–2 versus 19% in the MR CLEAN medical arm (P