Feasibility of Coronary Angiography and Percutaneous Coronary Intervention via Left Snuffbox Approach

Update on complications and their management during transradial cardiac catheterization

Introduction: Transradial artery access (TRA) was introduced in 1989 and has been universally used as an alternative approach to the traditional transfemoral access (TFA). Complications of TRA include asymptomatic and less likely symptomatic radial artery occlusion, nonocclusive radial artery injury, radial artery spasm, radial arterial perforation, radial artery pseudoaneurysm, arteriovenous fistula, granuloma formation, access-site bleeding, nerve damage, complex regional pain syndrome along with other rare complications.Areas covered: A literature search was performed using MedLine, PubMed, and Google Scholar (dating to 1 May 2019). Authors reviewed all articles related to transradial artery catheterization, its complications, as well as novel techniques for their management. The article provides insight on the incidence, risk factors, and prevention of such complications along with a description of usual and newer techniques to decrease morbidity.Expert opinion: With increasing experience, TRA complication rate is decreasing and new very uncommon complications are being described. A 'radial first' approach should be implemented in all catheterization laboratories and a physician's familiarity with minor and major complications is a must. Distal radial artery access through the snuff box might be the preferred site of accessing the radial artery and further studies will be needed to prove its superiority to the current access site.

Comparison of 4-French versus 5-French sheaths for diagnostic coronary angiography via the snuffbox approach

BACKGROUND

Although a shorter hemostasis duration would be expected when compared with the conventional radial approach as the diameter of the distal radial artery is smaller than that of the conventional radial artery, the optimal duration of hemostasis in diagnostic coronary angiography (CAG) via the distal radial approach, termed the snuffbox approach, has not been well investigated.

METHODS

Data from 171 patients were retrospectively collected (55 and 116 patients in the 4-French [Fr] and 5-Fr sheath groups, respectively). The patients had suspected myocardial ischemia and were undergoing diagnostic CAG via the snuffbox approach at a single center between January 2019 and August 2019.

RESULTS

The mean age of the study population was 67.6 ± 11.0 years, and 69% were male. The left snuffbox approach was performed in 146 (85.4%) patients. The mean snuffbox puncture time, defined as the time interval between local anesthesia and sheath cannulation, was 145.1 ± 120.8 s. The hemostasis duration was significantly shorter in the 4-Fr sheath group than in the 5-Fr sheath group (70 [62-90] vs. 120 [120-130] min; p < 0.001). There were local hematomas, defined as ≤ 5 cm in diameter, at the puncture site in 8 (4.7%) patients. Moreover, there were no conventional and distal radial artery occlusions, assessed by manual pulse, after hemostasis in the study population during hospitalization.

CONCLUSIONS

Successful hemostasis was obtained within 2 h for diagnostic CAG via the snuffbox approach using the 4-Fr or 5-Fr sheaths.

Left Distal Transradial Approach for Coronary Intervention: Insights from Early Clinical Experience and Future Directions

Left distal transradial approach is a novel technique for coronary intervention. This technique is convenient for specialists to operate and welcomed for right-handed patients. The anatomical snuffbox and the first intermetacarpal are two available puncture sites on the basis of hand anatomy. In technical aspects, main differences between left distal transradial approach and conventional transradial approach are patient's special position, puncture procedure, sheath choice, and hemostasis methods. According to the preliminary data, this technique is feasible and safe and it has low rate of complications including radial artery occlusion in forearm. Left distal transradial approach is a quite promising strategy of coronary intervention and deserves further exploration. In this review article, we describe the main technical characteristics and the results obtained from early clinical experiences. We also discuss the main challenges and future perspectives on this novel technique.

Distal Radial Access: A Review Article

Transradial approach (TRA) for coronary angiography and interventions has been increasingly used over the last decades and has become the default strategy in the majority of catheterization laboratories worldwide. Recently, a novel transradial access site, the distal radial access (DRA), has been proposed as an alternative to traditional TRA. Several case reports and case series have been published on this new approach over the last year showing overall good success rates. Aim of this review is to present the possible benefits and drawbacks of DRA and offer guidance on its successful use.

Right arm distal transradial (snuffbox) access for coronary catheterization: Initial experience

BACKGROUND

Distal transradial access (dTRA) by the snuffbox approach for coronary catheterization has emerged as an alternative to the classic forearm TRA with certain advantages and limitations.The aim of this study was to evaluate the effectiveness and safety of the dTRA exclusively from the right arm.

METHODS

Forty-nine consecutive patients (31 males and 18 females, mean age 64 ± 12 years), who were candidates for coronary catheterization in two cath laboratory centers, regardless of the indication, were recruited. Right dTRA was exclusively used. Radial artery patency both at the forearm and at the snuffbox region was evaluated 24 h after successful hemostasis by triplex ultrasonography. All complications were recorded until 24 h after the procedure.

RESULTS

The indication for catheterization was an acute coronary syndrome in 24.5%, stable coronary artery disease in 22.4%, and other reasons in 53.1%. The overall failure attempt incidence was 10.2% and the mean puncture time 3.9 ± 4.1 min. Angiography only was performed in 81.8% and angiography followed by percutaneous coronary intervention in 18.2% of the patients. Manual hemostasis was applied in 63.6% of the patients, which had a significantly shorter duration than device hemostasis (11 ± 7 versus 198 ± 42 min, p < 0.001). No distal or forearm radial artery occlusion was observed on triplex ultrasonography 24 h after successful hemostasis. No major complications were recorded.

CONCLUSIONS

This two-center study, utilizing exclusively the right dTRA, provides further data regarding the snuffbox approach in an all-comers population. Further worldwide reports will elucidate new aspects of the technique.