Comparison of Transradial and Transfemoral Access for Cerebral Digital Subtraction Angiography Across Different Aortic Arch Types: A Prospective Randomized Controlled Trial

Abstract

Objective:

To investigate the operational efficiency, safety, and postoperative recovery differences between the transradial approach (TRA) and the transfemoral approach (TFA) in performing digital subtraction angiography (DSA) in patients with different aortic arch types. Additionally, to compare the applicability of Simmon 1 and Simmon 2 catheters in complex aortic arch configurations.

Methods:

This single-center, prospective, randomized controlled trial included 114 patients with cerebrovascular disease scheduled for DSA. Preoperative aortic arch computed tomography angiography (CTA) was performed on all patients to classify the aortic arch into type I, type II, or type III, with 38 patients in each group. Each arch type was then randomly assigned in a 1:1 ratio to either the TRA (n=57) or TFA (n=57) group. The comparison between the 2 groups included puncture time, fluoroscopy time, contrast agent usage, postoperative hemostasis time, immobilization time, and the incidence of puncture-related complications for each aortic arch type. For patients with type III aortic arch in the TRA group, a further random allocation was made to use either the Simmon 1 or Simmon 2 catheter to assess differences in performance for complex arch types.

Results:

Baseline characteristics between the 2 groups were similar. Compared with the TFA group, the TRA group had a longer puncture time (29.08±1.53 min vs 20.11±1.65 min, p<0.001), but shorter fluoroscopy time (4.52 min vs 5.45 min, p<0.001), and significantly reduced postoperative hemostasis and immobilization times (both p<0.001). The incidence of puncture-related complications was significantly lower in the TRA group (1.75% vs 19.30%, p=0.006). In all aortic arch type subgroups, TRA demonstrated superior postoperative recovery and safety compared to TFA, with the most pronounced advantage observed in patients with type III aortic arch. Furthermore, in type III aortic arch patients within the TRA group, the use of Simmon 2 catheter significantly reduced contrast agent usage (43.73±6.20 mL vs 53.36±5.93 mL, p=0.002), shortened hemostasis and immobilization times (p<0.001), but there were no significant differences in puncture and fluoroscopy times.

Conclusion:

TRA demonstrated excellent safety and postoperative recovery advantages across different aortic arch types, with a particular adaptive benefit in type III aortic arch patients. The Simmon 2 catheter performed better in TRA-treated type III arch patients, supporting individualized approach and catheter selection based on preoperative aortic arch morphology. This strategy may improve procedural efficiency, reduce complications, and optimize patient outcomes. Further validation in larger, multicenter studies is recommended.

Clinical Impact

This study validates the TRA as a safer, more efficient alternative to transfemoral access for cerebral angiography, regardless of aortic arch complexity. It challenges the hesitation to use TRA in Type III arches by demonstrating significantly reduced complications and faster recovery. A key innovation is the stratified evaluation of catheters, identifying the Simmon 2 catheter as superior for Type III arches to optimize contrast usage and hemostasis. For clinicians, this supports shifting toward individualized, anatomy-based strategies, encouraging the use of TRA with specific catheter selection to improve safety and patient outcomes in neurointerventional procedures.