Direct Carotid Puncture for Mechanical Thrombectomy: Technical Advances in Access and Closure

BACKGROUND AND OBJECTIVES: Mechanical thrombectomy (MT) is the standard of care for patients with anterior circulation acute ischemic stroke with large-vessel occlusion and is traditionally performed through transfemoral access (TFA). In cases of difficult vascular anatomy, however, TFA may be prohibitive to achieving reperfusion in a timely manner, and alternative access methods must be used. Direct carotid puncture (DCP) has previously been described only as a bail-out access strategy fraught with complications, with inconsistent access and closure methods used. This study describes our DCP protocol and analyzes patient and procedural outcomes of MT performed through DCP, aiming to determine if expeditious DCP during MT can lead to safe and successful outcomes comparable with those of TFA. METHODS: Twenty-two patients who underwent MT through DCP at a single institution from 2017 through 2025 were retrospectively reviewed. Clinical details and outcomes data were collected, including indications for DCP, devices used, technical success of the procedure/revascularization scores, puncture, and revascularization times. RESULTS: Of 510 MT performed, 4.3% were via DCP. IV thrombolytic was administered in 45% of DCP cases. Reasons for conversion to DCP were for type 3 and/or tortuous arch (73%) or femoral/iliac artery occlusion/stenosis (27%). Average time from groin to carotid puncture was 30 minutes and from carotid puncture to reperfusion was 28 minutes, compared with our average reperfusion time of 22 minutes for TFA cases. Successful revascularization was achieved in 90.1% of DCP cases, with 0 procedural complications. All patients underwent sheath removal through carotid cutdown in the operating room after the endovascular procedure. CONCLUSION: DCP is a safe, feasible, and effective technique for revascularization in acute stroke intervention in patients with difficult anatomy. Given the average time from DCP to reperfusion is comparable with TFA, timely conversion to DCP up-front may improve procedural outcomes in cases of obvious complex anatomy.