Recanalization of the occluded radial artery via distal transradial access in the anatomic snuffbox

Overview of the distal radial access from the radial artery occlusion perspective

Conventional radial access in endovascular surgery has certain limitations, primarily associated with the presence of local complications and radial artery occlusion. Over the past 7 years, distal radial access has exploded into all areas of endovascular procedures, from interventional cardiology to vascular surgery and interventional oncology. However, puncture of the distal radial artery has its own nuances and features: a learning curve, the use of ultrasound navigation in the initial stages of mastering the access, limitations in patients with acute conditions (acute coronary syndrome and stroke). This review aims to analyze on important aspects of the procedure of distal radial access from preparation for it to hemostasis and to explore all data about the new roles of distal radial access in avoiding but also treating radial artery occlusion, as the first thing to begin with the development and implementation of new access.

Efficacy and safety of distal transradial access for coronary angiography and percutaneous coronary intervention: a meta-analysis

Introduction

This meta-analysis aims to evaluate the efficacy and safety of dTRA for coronary angiography (CAG) and percutaneous coronary intervention (PCI) in comparison to cTRA.

Materials and methods

Four databases (PubMed, Embase, Web of Science, and Cochrane Library) were searched from their inception to 13 April 2024 for studies comparing dTRA and cTRA in coronary diagnostic or interventional catheterization. The meta-analysis evaluated radial artery occlusion (RAO), procedure success, the success rate of catheter puncture, the success rate of a single attempt, hematoma occurrence, radial artery spasms, puncture site bleeding, puncture time, procedural time, the dosage of contrast medium, and hemostasis time.

Results

A total of 31 studies were included in the meta-analysis. Compared with cTRA, dTRA significantly reduced the incidence of RAO [odds ratio (OR) = 0.41, 95% CI: 0.34-0.50, P < 0.05], hematoma (OR = 0.67, 95% CI:0.56-0.80, P < 0.05), and shorter hemostasis time [weighted mean difference (WMD) = -0.43, 95% CI:-0.65 to -0.20, P < 0.05] but had a significantly lower procedure success rate (OR = 0.41, 95% CI: 0.30-0.56, P < 0.05), a lower catheter puncture success rate (OR = 0.44, 95% CI: 0.27-0.71, P < 0.05), and a longer puncture time (WMD = 0.60, 95% CI: 0.44-0.75, P < 0.05). No significant differences were observed between dTRA and cTRA in terms of the success rate of a single attempt, radial artery spasms, puncture site bleeding, procedural time, and dosage of contrast medium.

Conclusions

Our results revealed that dTRA is a workable and safe method for cardiovascular interventional diagnostics and treatment. It significantly reduces the incidence of RAO and hematoma, as well as shortens hemostasis time following surgery.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024596238, PROSPERO (CRD42024596238).

Treatment of radial artery occlusion after transradial coronary catheterization: a review of the literature and proposed treatment algorithm

The transradial artery has been established as the default access site for most coronary catheterization procedures with fewer access-related and bleeding complications, rapid hemostasis, early ambulation of the patient, and reduction in all-cause mortality compared with transfemoral access. However, radial artery occlusion (RAO) remains the most frequent complication of coronary catheterization procedures performed via transradial artery access. The purpose of our review was to conduct detailed literature research and summarize all the available treatment strategies for RAO, given the lack of a standardized treatment protocol in the literature. Pharmacological treatment with low-molecular-weight heparin (LMWH) or other anticoagulants, invasive strategies, and pharmaco-invasive methods available in the literature were included in our review. Data were derived from case series, case reports, clinical trials, and observational studies. Eight studies regarding pharmacological treatment with LMWH or any other anticoagulant and seven studies of invasive treatment were included in our review. There were only two randomized studies: one with LMWH (tinzaparin) and one with apixaban. Furthermore, taking into consideration data derived from the above-mentioned studies, a treatment algorithm for RAO was proposed. RAO remains the most frequent complication of coronary procedures with transradial access. Application of preventive strategies and comprehensive knowledge of the risk factors remain the key factors for the reduction of the incidence of this clinical entity. Therapeutic options include anticoagulation regimens and interventional techniques through the distal radial artery. Large, randomized, multicenter studies should be conducted to evaluate the efficacy of the available treatment methods and define a standardized treatment protocol for RAO.

Case report: Chronic radial artery occlusion treated with paclitaxel-coated balloon via distal transradial access

A 38-year-old male patient was diagnosed as acute non-ST-segment elevation myocardial infarction on Apr 21st 2021 and he received percutaneous transluminal coronary angioplasty for RCA via transradial artery access. He sought for second percutaneous coronary intervention in our center for frequently exertional angina on Sep 13th 2021. Proximal right radial artery pulsation can not be touched in physical examination, indicating right radial artery occlusion (RAO). Distal transradial access was applied and RAO was confirmed via angiography. With balloon pre-dilation, the guidewire and guiding catheter crossed the occlusion and coronary intervention was successfully completed. A Reewarm 2.5 × 220 mm paclitaxel drug-coated balloon (Endovastec, China) was released at 12 atm in radial arterial lesion with 90 s. Pulsation of radial artery can be well palpated 24 h after PCI. No oral anticoagulant was added. The right radial artery remained patent after 8-month and 14-month follow-up and there was no abnormal sensation or obstacle of right hand.

Feasibility of early radial artery occlusion recanalization and reuse through transradial access for neuroendovascular procedures

BACKGROUND

Radial artery occlusion (RAO) remains a significant limitation of neuroendovascular procedures peformed through transradial access (TRA) when radial artery needs to be reused. Instances of early RAO recanalization to successfully complete neuroendovascular procedures have been rarely documented.

MATERIALS AND METHODS

Documents and imaging data were extracted retrospectively for all patients who underwent TRA diagnostic angiography and neuroendovascular procedures in our center from June 2022 to February 2023. The patients with early RAO who required repeat TRA were included.

RESULTS

A total of 46 patients underwent repeat TRA, and 13 consecutive patients who experienced early RAO after angiography as confirmed by ultrasonography were enrolled in this study. The occluded radial arteries were successfully recanalized, and subsequent neuroendovascular procedures were carried out successful. During an average follow-up time of 7.1 months, no patients exhibited symptomatic RAO, dissection, hematoma or pseudoaneurysm.

CONCLUSIONS

Early RAO recanalization and reused for neuroendovascular procedures through TRA is feasible. A visually guided and stable puncture process plays a crucial role in successfully recanalizing early RAO.

Open Radial Artery Study

Radial artery occlusion (RAO) has been the most common postprocedural complication of transradial artery access. The optimal method of prevention of RAO is still lacking. In our study, we aimed to evaluate the effect of patent hemostasis on early (24 hours) and late (2 weeks) RAO prevention. The Open Radial Artery Study was a single-arm, prospective, and multicenter study. The primary end points were early and late RAO at the vascular access site after transradial coronary procedures. Secondary end points were access site hematoma, pseudoaneurysm formation, arteriovenous fistula, and nerve injury. A total of 2,181 patients were analyzed (67% male, mean age 68 years). The mean interventional duration and hemostatic times were 75.6 ± 55.6 and 60 ± 5.6 minutes, respectively. Radial artery spasm occurred in 10% of patients (n = 218). Catheter kinking, radial artery rupture, or dissection were not observed during the procedure. RAO, hematoma, pseudoaneurysm, arteriovenous fistula, or nerve damage was not observed in any of the patients in the early or late period. In patients who undergo coronary diagnostic or interventional procedures through transradial artery access, the patent hemostasis method seems a critical step in the prevention of early and late RAO.

Hepatic artery chemoembolization with distal transradial access for primary hepatocellular carcinoma: a novel interventional therapy for peripheral tumors

OBJECTIVE

To investigate the feasibility and safety of hepatic artery chemoembolization via the distal transradial access (dTRA).

METHODS

The clinical data of 130 patients with primary hepatocellular carcinoma treated in The First Hospital of Jilin University between August 1, 2020 and December 31, 2020, were retrospectively analyzed. Patients were confirmed to have primary hepatocellular carcinoma by preoperative imaging or pathology, with Child-Pugh Grade A or B and persistently palpable distal radial pulses. After a negative Allen test, patients underwent transcatheter arterial chemoembolization (TACE) via dTRA. The puncture success rate, the average number of needles, puncture time, distal radial occlusion and wrist hematoma were used to evaluate the treatment efficacy in the patients.

RESULTS

All the punctures were performed using 21G steel needles. 5F sheaths were used for 84 cases, and 4F sheaths for 46 cases. The total was 130 cases. Among the 130 cases, 112 cases (86.2%) were successful in the puncture, 18 cases (13.8%) failed in the puncture. The success rate of the descending aorta selection using an MPA1 catheter (Cordis, Santa Clara, CA, USA) was 96.2% (125/130). In the remaining 5 cases, the selection succeeded after a 5F pigtail catheter was used instead. The success rate of the celiac trunk or superior mesenteric artery selection using an MPA1 catheter was 100%. No bleeding or hematoma occurred after 2-4 hours of compression following distal radial artery puncture, and both distal and proximal radial artery pulses were palpable. No arterial dissection or pseudoaneurysm was found, and there was no distal radial artery occlusion. Fourteen patients underwent 2 sessions of distal radial artery punctures, and no vascular occlusion was found in these patients either.

CONCLUSIONS

TACE via the dTRA is feasible and safe for primary hepatocellular carcinoma.

Nurse-led distal radial access: efficacy, learning curve, and perspectives of an increasingly popular access. Does learning by doing apply to both the doctor and the nurse?

BACKGROUND

The distal radial represents an evolution of the standard radial approach. Distal radial arterial access (DRA) in the so-called "anatomical snuffbox" is technically more difficult but offers potential advantages for patients. Moreover, the use of the distal radial would preserve the proximal radial from the risk of arterial occlusion after interventional procedures performed through the radial artery.

METHODS

We enrolled 100 consecutive elective patients undergoing cardiac catheterization (diagnostic or procedural). Arterial access to the distal radial was entirely managed by nursing staff supervised by the interventional cardiologist. In this single-centre single-operator experienced study, the same nurse operator performed puncture, wiring, and sheath advancement.

RESULTS

The technical feasibility was 89% and the failure rate occurred in the first 50 cases as evidenced by the learning curve. There were no major complications and the rate of minor complications is in line with that of the radial literature. BMI (OR 1.19; 95% CI: 1.03-1.38), non-radial dominance (OR 3.5; 95% CI: 1.04-12.3) and operator's experience (OR 0.59; 95% CI: 0.35-0.99 for every 20 consecutive cases performed) were associated with DRA failures.

CONCLUSIONS

The experience is encouraging and beneficial for all staff and patients with a high percentage of technical success and few mild complications.

The anatomical snuffbox for transradial access in arteriovenous fistula intervention: Case report and brief review of the literature

Left distal transradial artery (dTRA) access in the anatomical snuffbox is a relatively novel technique and is considered beneficial when left TRA access is required. This technique offers essential advantages, including improved patient comfort and lower vascular complications. dTRA may provide an entry site for retrograde recanalization of the radial artery. We presented a case of a 65-year-old man with 5-stage chronic kidney disease (CKD) and had left a radio-cephalic arteriovenous fistula (AVF) for routine hemodialysis. There was obstruction of AVF a month after creation. The vascular intervention has been performed using left dTRA access for retrograde recanalization. Angiogram showed cephalic vein obstruction and non-significant stenosis of the proximal radial artery. Percutaneous transluminal angioplasty was successful in improving cephalic vein flow. Hemostatic performed without a hemostatic device. This case report highlights the dTRA access approach in the anatomical snuffbox to recanalize AVF occlusion in the wrist in a patient with CKD.

Distal Radial Artery Access for Recanalization of Radial Artery Occlusion and Repeat Intervention: A Single Center Experience

Background: Once occluded, the radial artery becomes unsuitable for repeat interventions and obligates the need for alternative vascular access, such as the femoral approach, which is not encouraged by current guidelines. With the dissemination of distal radial access (DRA), which allows the cannulation of the artery in its distal segment and which remains patent even in the case of radial artery occlusion (RAO), the option to perform angioplasty at this level becomes feasible. Methods: Thirty patients with RAO were enrolled in this pilot study. Recanalization was performed through DRA using hydrophilic guidewires. The feasibility endpoint was procedural success, namely the successful RAO recanalization, the efficacy endpoint was patency of the artery at 30 days, and the safety endpoint was the absence of periprocedural vascular major complications or major adverse cardiac and cerebrovascular events. Results: The mean age of the patients was 63 ± 11 years, and 15 patients (50%) were men. Most patients had asymptomatic RAO (n = 28, 93.3%), and only two (6.6%) reported numbness in their hands. The most common indication for the procedure was PCI (19, 63.2%). Total procedural time was 41 ± 22 min, while the amount of contrast used was 140 ± 28 mL. Procedural success was 100% (n = 30). Moreover, there were no major vascular complications (0%); only two small hematomas were described (10%) and one had an angiographically visible perforation (3%). One case of periprocedural stroke was reported (3%), with onset immediately after the procedure and recovering 24 h later. Twenty-seven radial arteries (90%) remained patent at the one-month follow-up. Conclusions: RAO recanalization is feasible and safe, and by using dedicated hydrophilic guidewires, the success rate is high without significantly increasing procedural time or the amount of used contrast.

Retrograde recanalization of radial artery occlusion via the distal transradial artery: A single-center experience

Background

Radial artery occlusion (RAO) often occurs after catheterization when using a transradial artery approach.

Objective

This prospective study assessed the success and feasibility of accessing the distal transradial artery (dTRA) for retrograde recanalization of RAO.

Methods

From June 2019 to December 2021, 44 consecutive patients who had undergone cardiac catheterization resulting in RAO were given retrograde recanalization via the dTRA. According to the result of the procedure (primary endpoint), patients' cases were analyzed as successful or failed. Rates of post-operative patency and adverse events were calculated up to 12 months.

Results

The procedural success rate was 88.6%. Compared with the successful group, a significantly higher percentage of patients in the failed group were current smokers and/or suffered from diabetes mellitus (each, 80.0% cf. 33.3%, P = 0.046); had undergone at least 3 previous cardiac catheterizations (60.0% cf. 12.8%, P = 0.011), lower rate of anticoagulation (30.77% cf. 0%, P = 0.048) and exhibited chronic total occlusion (100.0% cf. 51.28%, P = 0.041). In each group, one patient each had minor bleeding at the access site and hematoma. The patency rates in the successful group at postoperative 3, 6, and 12 months were 48.7, 43.6, and 35.9%, respectively.

Conclusion

The dTRA approach for retrograde recanalization of RAO showed a high procedural success rate, but with patency rates of <50% at follow-up.