Objective:

To compare the rates of hemorrhagic and non-hemorrhagic femoral access-site complications between Tenecteplase (TNK) and Alteplase (TPA) bridging thrombolysis in patients undergoing stroke thrombectomy.

Background:

Access-site complications, particularly with the transfemoral approach, are a known risk in stroke thrombectomy. Bridging thrombolysis may increase the risk for hemorrhagic complications.

Design/Methods:

We retrospectively reviewed large vessel occlusion stroke (LVOS) patients (>18 years) treated with intravenous thrombolysis (IVT) followed by emergent endovascular treatment (EVT) from January 2020 to May 2024 (n=280). Eleven patients were excluded due to rapid recovery after thrombolysis, negating the need for EVT. Access routes were categorized as transfemoral, transradial, transbrachial, or transcarotid. Complications were grouped into hematomas, pseudoaneurysm, and arterial occlusion. Major complications were defined as those requiring surgical or interventional treatment.

Results:

Of the 269 patients who underwent IVT and EVT, TPA was administered in 99 (35.4%) and TNK in 181 (64.6%). Access routes were predominantly transfemoral (95.5%), with transradial (3.7%), transbrachial (0.4%), and transcarotid (0.4%) used less frequently. Access-site complications occurred exclusively in the transfemoral group. Hematomas occurred in 22 cases (8.6%), pseudoaneurysms in 4 (1.6%), and arterial occlusions requiring surgical repair in 2 (0.8%). One pseudoaneurysm required thrombin injection (0.4%), while the others were managed conservatively. Hematoma rates were comparable between TPA and TNK groups (p=0.488). Coronary artery disease was the strongest predictor of hematoma occurrence, while platelet count, INR, thrombolytic-administration-to-femoral-puncture time, and arteriotomy closure method were not associated with complications. Antithrombotic use and atrial fibrillation were the strongest predictors of overall access-site complications.

Conclusions:

Hemorrhagic and non-hemorrhagic access-site complications were low and comparable between TNK and TPA. Coronary artery disease and antithrombotic use were significant predictors of access-site complications, but thrombolytic type did not influence the complication rate. Notably, complications occurred exclusively with transfemoral access.