Comparison of distal radial access versus standard transradial access in patients with smaller diameter radial Arteries(The distal radial versus transradial access in small transradial ArteriesStudy: D.A.T.A - S.T.A.R study)

A narrative review of history, advantages, future developments of the distal radial access

This article presents a historical excursus and a review of modern literature on distal radial access for interventional surgery, discussing the anatomical and physiological substantiation of the use of this access point in endovascular surgery, its advantages and disadvantages. The main considerations directly related to distal puncture, choice of instrumentation, hemostasis, possible complications, and prevention are analyzed. The major areas of interventional surgery (coronary, vascular, oncological, and neurointerventional), where the distal radial approach is actively used, are reflected and their characteristics are highlighted. In general, it has been shown that with the development of technology, improved manual skills, the widespread use of hydrophilic introducers, and modern sheathless guiding catheters, the vessel diameter, and puncture site are not decisive factors when choosing access for any type of intervention.

Impact of sex differences on the feasibility and safety of distal radial access for coronary procedures: a multicenter prospective observational study

BACKGROUND

Conventional transradial access in women is associated with a lower success rate and a higher incidence of spasm compared to men. To date, the effect of sex on the performance of distal radial access (DRA) has not been fully elucidated. The aim of this study was to assess the impact of sex on catheterization success and other performance parameters of DRA procedures.

METHODS

This is a prospective three-center observational study. From August 2020 to September 2022, data from all consecutive patients who underwent DRA for coronary procedures were collected.

RESULTS

A total of 868 procedures were registered and stratified into two groups according to sex: women (n = 258) and men (n = 610). Female patients had less favorable baseline characteristics than male patients in terms of absent or weak pulse (29% vs. 17%; P < 0.001), distal radial diameter (2.2 ± 0.3 vs. 2.4 ± 0.4 mm; P < 0.001) and proximal radial diameter (2.5 ± 0.7 vs. 2.7 ± 0.7 mm; P = 0.001). No differences in success rates were found in women compared to men (94.2% vs. 96.6%; P = 0.135), with a higher presence of arterial spasm in women (5.8% vs. 3.0%; P = 0.044). The preprocedural ultrasound evaluation was the only predictor of DRA success [odds ratio = 20.0 (4.739-83.333); P < 0.001].

CONCLUSION

In patients undergoing coronary procedures, the success rate of DRA was high regardless of sex, with a higher incidence of arterial spasm in women.

Distal Radial Access: Is There a Clinical Benefit?

For decades, the femoral artery has been the most common vascular access for diagnostic and therapeutic endovascular procedures. However, over the past 20 years, radial access has been gaining popularity, as it is a safer and allows practical access with more benefits. Recently, the new distal radial access has proven to be an equal or perhaps even safer vascular access for diagnostic and therapeutic coronary and noncoronary interventions. Today, this access should be in the arsenal of every interventional surgeon.

Distal radial approach for arterial pressure monitoring with a long catheter provides safe and stable monitoring in the intensive care unit: A single-center retrospective study

BACKGROUND

To compare the distal radial artery approach (DRA) with a longer catheter to DRA with a shorter catheter in arterial catheter (AC) placement in the intensive care unit (ICU).

METHODS

This was a single-center retrospective cohort study of DRA with a long catheter (60 mm) for arterial catheterization in the ICU. DRA with a short catheter (25-30 mm) was used in the control group, and the groups were compared using multivariate regression analysis. The primary study endpoint was the incidence of unplanned AC removal. The secondary endpoint was the incidence of other inappropriate events, namely loss of arterial pressure waveforms, bleeding, catheter-related infection, pressure ulcer, and other complications associated with the AC.

RESULTS

In this study, the DRA with a long catheter was used in 50 patients. No unplanned AC removals or other inappropriate events occurred, and there were no complications associated with the DRA. The DRA procedural success rate was 100%. There was no significant difference in hemostasis times between the groups. Loss of arterial waveforms was an early predictor of unplanned AC removal.

CONCLUSIONS

The DRA with a long catheter provided stable monitoring and was associated with a low unplanned removal rate. This method has the advantages of fewer complications and shorter hemostasis time compared with the DRA with a short catheter, and may become a new AC option in the ICU.

Prospective evaluation of efficacy and safety of distal radial and radial artery access using a novel articulating-tip guidewire

BACKGROUND

Guidewire-facilitated access to peripheral vessels is commonplace in vascular access, but guidewire insertion into small vessels, such as the radial and distal radial arteries, can still be challenging. Failure to gain access on the first attempt may contribute to increased risks of procedural complications, such as vessel dissection, spasm, and occlusion. This research assessed the safety and efficacy of radial and distal radial artery access using a novel, FDA-cleared, small-core-diameter guidewire with an articulating tip, under ultrasound guidance.

METHODS

This was a prospective, single-arm, single-center trial. Patients in need of vascular access were screened for participation and enrolled in the study. Guidewire insertion was attempted by four physicians (three interventional radiologists and an interventional nephrologist) at 162 arterial sites-65 radial and 97 distal radial, having a mean diameter of 2.0 mm.

RESULTS

First-attempt successful placement of the guidewire in the artery occurred at 87.6% of access sites (142/162) and differences in the success rate between the radial and distal radial arteries or between vessels with diameter smaller or larger than 2 mm were not observed (62/68 and 67/77, respectively; p = 0.6). Four of the five reported adverse events were unrelated to the study device or procedure. Two of the three distal radial artery spasms occurred before the guidewire was used. The other two events were a radial artery spasm, and a distal radial artery site hematoma. All adverse events resolved spontaneously.

CONCLUSIONS

First-attempt placement of a novel articulating tip guidewire in the radial and distal radial arteries occurred at a high rate in our study and was not associated with safety concerns.

Distal versus conventional radial artery access for coronary catheterization: A systematic review and meta-analysis

BACKGROUND

The distal radial artery (DRA) access is an alternative to the conventional radial artery (CRA) access for coronary angiography and interventions and appears to be associated with reduced incidence of certain outcomes.

METHODS

A systematic review was performed to evaluate differences between DRA versus CRA access for coronary angiography and/or interventions. Following preferred reporting items for systematic review and meta-analysis-protocols guidelines, two reviewers independently selected studies published in the electronic databases (MEDLINE, EMBASE, SCOPUS, CENTRAL) from inception to October 10, 2022, followed by data extraction, meta-analysis, and quality assessment.

RESULTS

The final review included 28 studies with (total: 9151 patients [DRA: 4474; CRA: 4677]). Compared with CRA, DRA access was found to be associated with a shorter time to achieve hemostasis (mean difference, MD: -32.49 [95% confidence interval, CI: -65.53, -2.46], p < 0.00001), and reduced incidence of radial artery occlusion (RAO) (risk ratio, RR: 0.38 [95% CI: 0.25, 0.57], p < 0.00001), any bleeding (RR: 0.44 [95% CI: 0.22, 0.86], p = 0.02), and pseudoaneurysm (RR: 0.41 [95% CI: 0.18, 0.99], p = 0.05). However, DRA access has increased access time (MD: 0.31 [95% CI: -0.09, 0.71], p < 0.00001) and crossover rates (RR: 2.75 [95% CI: 1.70, 4.44], p < 0.00001). There were no statistically significant differences in other technical aspects and complications.

CONCLUSION

DRA access is a safe and feasible approach for coronary angiography and interventions. Compared to CRA, DRA provides a shorter hemostasis time, lower incidence of RAO, any bleeding, and pseudoaneurysm, and is associated with increased access time and crossover rates.

A Meta-Analysis of Traditional Radial Access and Distal Radial Access in Transradial Access for Percutaneous Coronary Procedures

INTRODUCTION

Radial approaches are classified into traditional radial access (TRA) and more contemporary distal radial access (DRA), with recently published comparative studies reporting inconsistent outcomes. As there have been several recent randomized control trials (RCT), we assessed the totality of evidence in an updated meta-analysis to compare outcomes of DRA and TRA.

METHODS

We searched PubMed, CENTRAL, Web of Science, EMBASE, and Cochrane Database of Systematic Reviews from inception to August 2022 for studies comparing DRA and TRA for coronary angiography. Primary outcomes were the rate of radial artery occlusion (RAO) and access failure. Secondary outcomes included hematomas and puncture site bleeding. The pooled risk ratio (RR) with 95 % confidence interval (95 % CI) was calculated for each outcome.

RESULTS

A total of 14,071 patients undergoing coronary angiography from 23 studies, including 5488 patients from 10 RCTs. The mean age of the study population was 59.8 ± 5.9 years with 66.2 % men. Outcomes for a total of 6796 (48.3 %) patients undergoing DRA and 7166 (50.9 %) patients undergoing TRA were compared. DRA was associated with a lower rate of RAO (RR = 0.36, 95CI [0.27, 0.48], I2 = 0 %) but an increased risk of vascular access failure (RR = 2.38, 95CI [1.46, 3.87], I2 = 82.7 %). There was no significant difference in the rate of bleeding or hematoma formation.

CONCLUSION

In an updated metanalysis, DRA is associated with lower rates of RAO but with higher rates of access failure.

The technical features of the diagnosis or treatment of coronary artery disease through the distal radial artery approach at the anatomical snuffbox compared with the conventional radial artery approach

Background

To compare the surgical effects of coronary intervention through the transradial intervention (TRI) versus distal transradial intervention (dTRI) approach.

Methods

From September 2020 to April 2021, 302 patients undergoing coronary artery angiography (CAG) or percutaneous coronary intervention in our hospital were retrospectively included. Patients were divided into the TRI group and dTRI group with 151 cases in each group. The technique features, lesion features, and cannulation process were compared between the two groups.

Results

The number of patients who underwent CAG in the dTRI group (35.1%) was significantly greater compared with the TRI group (12.6%) (P < 0.01). The rates of triple vessel lesions, calcification lesions and chronic total occlusion lesions were increased in the TRI group compared with the dTRI group (P < 0.05). The average radial artery diameter (RAD) in the TRI group (2.550 ± 0.417 mm) was greater than that in the dTRI group (2.070 ± 0.360 mm) (P < 0.05). The hemostasis time of the dTRI group (173.272 ± 41.807 min) was lower than that of the TRI group (273.417 ± 42.098 min) (P < 0.05). The radial artery occlusion (RAO) rates in the dTRI group (2.6%) were lower than those in the TRI group (8.6%) (P < 0.05). The dTRI group had a higher satisfaction score than the TRI group (P > 0.05). RAD at the puncture site was a predictor of the overall cannulation success rate with an AUC of 0.747 (95% CI 0.663–0.860; P < 0.05).

Conclusions

Despite a steep learning curve, the dTRI approach had a shorter hemostasis time, reduced RAO rates, and notable preliminary safety results compared with the TRI approach. The dTRI approach can be used as a supplemental method to the TRI approach.

Comparison between the Right and Left Distal Radial Access for Patients Undergoing Coronary Procedures: A Propensity Score Matching Analysis

Introduction

Distal radial access for coronary procedures decreases hemostasis time, prevents radial occlusion, and improves patient comfort compared to conventional transradial access. Initially described for left distal radial access (lDRA), the right distal radial access (rDRA) is feasible. However, there are no comparative studies to date. This study aimed to evaluate the impact of the access site on vascular access and procedural performance.

Methods

From August 2020 to October 2021, coronary procedures performed through distal radial access were prospectively recorded. After propensity score matching, the rDRA and lDRA were compared. The primary endpoint was the proportion of approach success. The secondary endpoints included access time, coronary procedural success, radial spasm, exposition to ionizing radiation, patient comfort, and vascular access-related complications.

Results

From a total of 385 procedures in 382 patients, after a propensity score matching, 182 procedures were compared between the rDRA and lDRA. There were no differences in the baseline characteristics between the groups. Compared to the lDRA, the rDRA presented similar approach success (96.7% vs. 96.7%, p=1.0), less access time (39 (25–60) sec vs. 50 (29–90) sec, p=0.018), comparable coronary procedural success after sheath placement (100% vs. 100%, p=1.000), and not statistically significant radial spasm (2.19% vs. 6.59%, p=0.148). No differences in dose-area product (32 (20–56.2) Gy.m2 vs. 32.3 (19.4–46.3) Gy.m2; p=0.472) and fluoroscopy time (4.4 (2.5–9.1) min vs. 4.3 (2.4–7.5) min, p=0.251) were detected between the groups. No vascular access-related complications were observed in any group.

Conclusions

The rDRA, compared to the lDRA, had the same proportion of approach success and procedural performance, with a slight reduction in access time for patients undergoing coronary procedures.

Meta-Analysis Comparing Distal Radial Versus Traditional Radial Percutaneous Coronary Intervention or Angiography

Data comparing outcomes of distal radial (DR) and traditional radial (TR) access of coronary angiography and percutaneous coronary intervention (PCI) are limited. Online databases including Medline and Cochrane Central databases were explored to identify studies that compared DR and TR access for PCI. The primary outcome was the rate of radial artery occlusion (RAO) and access failure. Secondary outcomes included access site hematoma, access site bleeding, access site pain, radial artery spasm, radial artery dissection, and crossover. Unadjusted odds ratios (ORs) with a random-effect model, 95% confidence interval (CI), and p <0.05 were used for statistical significance. Metaregression was performed for 16 studies with 9,973 (DR 4,750 and TR 5,523) patients were included. Compared with TR, DR was associated with lower risk of RAO (OR 0.51, 95% CI 0.29 to 0.90, I² = 42.6%, p = 0.02). RAO was lower in DR undergoing coronary angiography rather than PCI. Access failure rate (OR 1.77, 95% CI 0.69 to 4.55, I² 87.36%, p = 0.24), access site hematoma (OR 1.11, 95% CI 0.68 to 1.83, I² 0%, p = 0.68), access site pain (OR 2.22, 95% CI 0.28 to 17.38, I² 0%, p = 0.45), access site bleeding (OR 1.11, 95% CI 0.16 to 7.62, I² 85.11%, p = 0.91), radial artery spasm (OR 0.79, 95% CI 0.49 to 1.29, I² 0%, p = 0.35), radial artery dissection (OR 1.63, 95% CI 0.46 to 5.84, I² 0%, p = 0.45), and crossover (OR 1.54, 95% CI 0.64 to 3.70, I² 25.48%, p = 0.33) did not show any significant difference. DR was associated with lower incidence RAO when compared with TR, whereas other procedural-related complications were similar.

Safety and Feasibility of Ultrasound-Guided Access for Coronary Interventions through Distal Left Radial Route

Aims

Left distal transradial arterial approach (ldTRA) is a new interventional route that spares right radial artery (RRA) for use in haemodialysis and as bypass graft. Vasant Kunj Left dIstal Transradial ArtEry approach (VKLITE) study aimed to assess the feasibility and safety of ldTRA access during coronary angiography (CAG) and percutaneous coronary intervention (PCI).

Methods and Results

Between April 2018 and June 2020, 108 patients were enrolled and underwent CAG ± PCI via ultrasound guided ldTRA. Arterial puncture, CAG, and PCI were successful in 96.3% (104/108), 92.1% (93/101), and 94.1% (32/34) patients, respectively. Access site crossover rate was 14/108 (13.0%). Mean puncture, procedure, and haemostasis time (minutes) were 6.7 ± 7.1, 55.7 ± 32.8, and 23.1 ± 11.9. Median total fluoroscopic time was 6.6 minutes (IQR-14.2), and median total radiation dose was 39.2 Gy-cm² (IQR-97.0). Local haematoma occurred in 11 patients (10.2%) with major haematoma in 1.9%, all recovering within three weeks. Mean pain score was 2.4 ± 2.3, and patient satisfaction score was 9.0 ± 1.3. LdTRA access compared with RRA access (n = 121) showed significantly increased mean procedure time (55.7 ± 32.8 vs. 43.9 ± 26.0 minutes, p = 0.01) and median total fluoroscopic time (6.6 [IQR-14.2] vs. 4.7 [IQR-8.2] minutes, p = 0.02), with similar median total radiation dose (39.2 [IQR-97.0] vs. 43.8 [IQR-54.5] Gy-cm², p = 0.56). No radial artery loss, dissection, pseudoaneurysm, arteriovenous fistula, or nerve injury was noted.

Conclusions

LdTRA access is feasible with few complications during CAG/PCI. Patient comfort and satisfaction makes it a desirable route for coronary interventions.

Distal Radial Artery Access for Coronary and Peripheral Procedures: A Multicenter Experience

INTRODUCTION

Distal radial access (dRA) has recently gained global popularity as an alternative access route for vascular procedures. Among the benefits of dRA are the low risk of entry site bleeding complications, the low rate of radial artery occlusion, and improved patient and operator comfort. The aim of this large multicenter registry was to demonstrate the feasibility and safety of dRA in a wide variety of routine procedures in the catheterization laboratory, ranging from coronary angiography and percutaneous coronary intervention to peripheral procedures.

METHODS

The study comprised 1240 patients who underwent coronary angiography, PCI or noncoronary procedures through dRA in two Hungarian centers from January 2019 to April 2021. Baseline patient characteristics, number and duration of arterial punctures, procedural success rate, crossover rate, postoperative compression time, complications, hospitalization duration, and different learning curves were analyzed.

RESULTS

The average patient age was 66.4 years, with 66.8% of patients being male. The majority of patients (74.04%) underwent a coronary procedure, whereas 25.96% were involved in noncoronary interventions. dRA was successfully punctured in 97% of all patients, in all cases with ultrasound guidance. Access site crossover was performed in 2.58% of the patients, mainly via the contralateral dRA. After experiencing 150 cases, the dRA success rate plateaued at >96%. Our dedicated dRA step-by step protocol resulted in high open radial artery (RA) rates: distal and proximal RA pulses were palpable in 99.68% of all patients at hospital discharge. The rate of minor vascular complications was low (1.5%). A threshold of 50 cases was sufficient for already skilled radial operators to establish a reliable procedural method of dRA access.

CONCLUSION

The implementation of distal radial artery access in the everyday routine of a catheterization laboratory for coronary and noncoronary interventions is feasible and safe with an acceptable learning curve.

Anatomical snuff box approach for percutaneous coronary interventions - Current status

Anatomical snuff box or distal radial artery approach for various percutaneous coronary angiograms and interventions has gained increased interest in recent years. The main advantage is the ergonomic comfort to the patient as it allows the patient's arm to be in more natural position. The safety and feasibility of this novel approach has been studied in past few years but still the data is limited and the distal radial artery approach has not been included in the guidelines. The present review focuses on the latest evidence, technique, advantages and disadvantages of this distal radial artery access.