Clinical Outcomes of Shifting from Transfemoral-First to Transradial-First Approach in Carotid Artery Stenting: A Retrospective Two-Timeframe Comparison at a Single Center

<b>Objective:</b> Carotid artery stenting (CAS) has traditionally been performed using the transfemoral approach (TFA). Recently, the transradial approach (TRA) has gained attention for its lower invasiveness and reduced complication risk. This study compares outcomes between two access strategy timeframes, TFA-first and TRA-first, to evaluate how this shift influences outcomes in a real-world setting. <b>Methods:</b> A retrospective analysis of 85 CAS procedures was conducted at our institution from October 2018 to September 2024, categorizing them into TFA-first (n = 42) and TRA-first (n = 43) periods. The primary endpoint was access-related complications and 30-day perioperative events, including stroke, myocardial infarction, and mortality. The secondary endpoints included target lesion access success rate, frequency of access route conversions, procedural time, and hospital length of stay. <b>Results:</b> Baseline characteristics, including age, sex, symptomatic status, stenosis severity, plaque characteristics, and anatomical considerations, were comparable between groups. In the TFA-first period, 88% of procedures utilized TFA, and TRA was not used at all, while the remaining 12% employed the transbrachial approach (TBA). In the TRA-first period, 23% of procedures employed TFA, 60% utilized TRA, and 16% relied on TBA (<i>p</i> < 0.01). Both groups achieved a similar rate of target lesion access success (98% each) with only one conversion per group. The primary endpoint was significantly lower in the TRA-first group (0%) compared to the TFA-first group (10%, <i>p</i> = 0.04), primarily due to reduced access-site complications. Additionally, the median hospital stay was shorter in the TRA-first group at 6 days compared to 10 days (<i>p</i> = 0.02). <b>Conclusions:</b> Adopting a TRA-first strategy over TFA in CAS leads to better outcomes by improving access-site safety and reducing hospital stays. Developing TRA-specific devices could further expand the applicability of TRA in CAS.