Coronary angiography using the left distal radial approach - An alternative site to conventional radial coronary angiography

Can Distal Radial Access Replace Conventional Radial Access for Coronary Catheterization? A Study Comparing Puncture Time, Attempts, Patient and Operator Comfort

BACKGROUND

To compare distal (dTRA) and classical (cTRA) transradial approaches for coronary catheterization with respect to puncture attempts, puncture time, operator and patient comfort, and safety outcomes.

METHODS

In this prospective observational study, patients undergoing coronary catheterization for standard indications via dTRA or cTRA approaches from July 2019 to May 2020 were included. Clinicodemographic and laboratory characteristics were recorded. Puncture time, number of puncture attempts, operator and patient comfort on the visual analogue scale (VAS), and access site complications like hematoma and radial artery occlusion were recorded. Patients were analyzed in the same group as the initial puncture, even if there was a cross-over.

RESULTS

Of the 130 patients (40.8% women), 50.8% and 49.2% belonged to dTRA and cTRA groups, respectively. dTRA group required more than one puncture attempt more frequently than cTRA group (30.3% vs. 15.6%; P =.047); consequently, puncture time was longer (60s vs. 50s; P =.031, respectively). However, puncture time was comparable if the puncture was successful in the first attempt (47.5s vs. 45s; P =.492). Patient comfort was comparable (7.2 ± 0.9 vs. 7.2 ± 1.2; P =.852), but operator comfort was more with cTRA approach (8.3 ± 1.6 vs. 8.8 ± 1.2; P =.048). Post-procedure, cTRA had more minor bleeding than dTRA approach. There was no major bleeding in either group. The occurrence of radial artery occlusion was comparable in both groups.

CONCLUSION

Although dTRA needed more attempts for successful puncture, puncture time was comparable with cTRA when puncture was successful on the first attempt. Therefore, one attempt at dTRA puncture could be a reasonable approach in patients undergoing coronary catheterization.

Electrophysiological Assessment of Paresthesia in Patients Following Radial Angiography: A Prospective Study

BACKGROUND

Radial angiography, preferred for its safety and comfort in percutaneous coronary interventions, occasionally leads to paresthesia-a tingling or numbing sensation in the hand. This study aimed to investigate the presence of nerve damage in patients experiencing paresthesia post-radial angiography through electrophysiological examination.

METHODS

This prospective study involved 77 patients who developed hand paresthesia following radial angiography. Excluded were those with malignancy, pregnancy, pace-makers, or recent angiography. Nerve conduction studies were performed using the Neuropack MEB 9102K EMG device, assessing sensory and motor amplitudes, latencies, and velocities of median, ulnar, and radial nerves.

RESULTS

The study included 77 patients (23 females, 54 males; average age 58.39 ± 10.44 years). In 11 diabetic patients, polyneuropathy was detected. For the remaining 66 patients, electrophysiological evaluations showed no significant pathological findings. Comparative analysis of both upper extremities revealed no significant differences in nerve conduction parameters between the side where angiography was performed and the other side. Despite paresthesia complaints, no electrophysiological evidence of nerve damage was found, suggesting that symptoms might be due to local irritation rather than direct nerve injury. This aligns with the safety profile of radial angiography and underscores the importance of distinguishing between transient paresthesia and serious nerve complications.

CONCLUSION

Paresthesia post-radial angiography, while clinically notable, is not typically associated with nerve damage. This study is significant as it is the first in the literature to demonstrate that radial angiography does not cause nerve damage.

Randomized comparison of Glidesheath Slender with conventional 5Fr arterial sheaths for coronary angiography through the distal radial artery

BACKGROUND

The potential benefits of the thin-walled 5F Glidesheath Slender sheath in the distal transradial access (dTRA) have not been investigated. This study aimed to compare the Glidesheath Slender versus conventional 5Fr arterial sheaths in patients undergoing diagnostic coronary angiography (CAG) through the dTRA.

METHODS

A total of 352 consecutive patients with an indication for CAG were randomized (1:1) to Glidesheath Slender 5Fr versus a conventional 5Fr arterial sheath for dTRA. The primary endpoint was the rate of successful hemostasis at 30 minutes after sheath removal. Follow-up ultrasound of the right radial and distal radial artery was performed 7-10 days after the procedure.

RESULTS

After exclusion of patients where a 6Fr sheath or crossover of access site was required, 108 patients in the Glidesheath Slender and 105 patients in the conventional 5Fr arterial sheath group were included in the analysis. The crossover rate to conventional radial access and the rate of successful hemostasis at 30 minutes after sheath removal were similar between the two groups (18.9% in the Glidesheath slender vs. 22% in the control group; P=0.460, and 62% vs. 51.4%; P=0.118, respectively). The level of pain associated with the procedure was significantly lower in the Glidesheath Slender group (2.69 vs. 3.29 in the control group; P=0.02). No significant difference was recorded between the two groups in the rate of access-related complications.

CONCLUSIONS

Use of Glidesheath Slender for dTRA did not increase the rate of early hemostasis compared with conventional arterial sheath.

Evaluation of a new insertion site for arterial pressure line in intensive care unit management: a prospective study

The arterial pressure line (A-line) is primarily inserted through the radial artery. However, accidental removal due to joint movement can be problematic in the intensive care unit (ICU). This study aimed to evaluate the safety and effectiveness of A-line insertion in the ICU through the distal radial approach (DRA), which is used in cardiac catheterization. This single-center, prospective, comparative study included 200 patients (≥ 20 years) who were brought to our hospital for emergency care and required A-line insertion. Patients were quasi-randomized to the traditional radial approach (TRA) or DRA. Data were recorded at the time of A-line insertion, administration, and removal. We evaluated the vessel diameter, number of punctures, success of the procedure, presence of complications, such as infection during management, and time taken for hemostasis after catheter removal. The primary endpoint was the accidental removal rate. Due to incomplete information, data were collected for 193 patients (96 TRA and 97 DRA). Successful procedures were observed in 95 of the 96 patients with TRA and 94 of the 97 patients with DRA. Guidewire use during insertion was significantly more common in the DRA group (P < 0.01) and post-puncture splint fixation was significantly more common in the TRA group (P < 0.01). Accidental removal, the primary endpoint, was observed in 10 patients with TRAs and 11 patients with DRAs, with no significant difference between the two groups (P > 0.99). DRA is as safe and effective as the TRA, suggesting that it is useful as a new A-line insertion site.

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.

A preliminary analysis of a prospective multicenter randomized controlled study of the efficacy and safety on traditional and distal radial access in interventional cardiology

Background: Despite the obvious advantages of transradial access and its widespread use, there are technical problems that force interventional surgeons to improve the methods of endovascular interventions. Aims: to analyze the effectiveness and safety of distal and traditional radial access for endovascular interventions. Methods: The study included 282 patients who underwent an endovascular intervention with distal radial access (DRA, 139 patients) or traditional radial access (TRA, 143 patients). The study is registered at www.clinicaltrials.gov, NCT04211584. Results: The median diameter of the radial artery in its proximal part, i.e. at the site of TRA, was 2.5 mm [Q1; Q3: 2.27; 2.8], in the DRA group the median was 2.28 mm [Q1; Q3: 2.06; 3.56], p 0.0001. We noted statistically significant differences in the duration of puncture (p=0.0215), but not in the duration of the introducer insertion, catheterization of the coronary artery, fluoroscopy, the total time of intervention, the dose of ionizing radiation. In total, 28 complications developed (9.9% of 282): 14 in each of the groups in one year after the intervention. Two (0.7% of 282) patients developed bleeding [1 (0.7% of 139) DRA, 1 (0.7% of 143) TRA], 5 (1.8% of 282) radial artery dissection [2 (1.4% of 139) DRA, 3 (2.1% of 143) TRA], 9 (3.2% of 282) puncture failure [7 (5% of 139) DRA, 2 (1.4% of 143) TRA], 4 (1.4% of 282) radial artery perforation [2 (1.4% of 139) DRA, 2 (1.4% of 143) TRA], 7 (2.5% of 282) hematoma more than 5 cm [2 (1.4% of 139) DRA, 5 (3.5% of 143) TRA], 1 (0.4% of 282) radial artery thrombosis [(0.7% of 143) TRA]. The risk of complications did not depend on the type of access. Conclusions: Distal and traditional radial access do not differ in their efficiency and safety. At the same time, we noted a certain tendency to a longer puncture of the radial artery with distal radial access compared to the traditional one, which is due to the smaller diameter of the radial artery.

Bilateral Distal Transradial Approach for Coiling of Basilar Artery Aneurysm: A Technical Note

Distal transradial approach (dTRA) for neuroendovascular procedures has received much attention in recent years as a newer and less invasive alternative to the conventional transfemoral or transradial approaches. We present the case of an 89-year-old woman with a basilar artery aneurysm requiring simultaneous catheterization of the bilateral vertebral arteries who was successfully embolized using bilateral dTRA. The aneurysm was accessed from the right vertebral artery using the right dTRA. Control angiograms during the procedure were performed from the left vertebral artery via the left dTRA. The operator's posture was ergonomically comfortable, and the catheters were easy to handle during the procedure. To the best of our knowledge, this is the first case of a bilateral dTRA used for neuroendovascular procedures. Bilateral dTRA is a safe and minimally invasive method for patients and ergonomically comfortable for operators.

Distal radial approach between theory and clinical practice.. Time to go distal!

Background

Transradial access (TRA), which has a minimal risk of problems such as radial artery occlusion (RAO), hemorrhage, spasm, and so on, is now considered the standard procedure for cardiac catheterization. The aim of the study is to present the distal transradial access (d-TRA) as a possible promising novel technique in the field of cardiac coronary interventions comparing it to the standard conventional TRA using primary and secondary endpoints, exploring its benefits and drawbacks as a new experience in Alexandria University. One hundred cases with variable indications for coronary interventions were randomized to two arms using systematic random sampling method, coronary interventions in the first one were done via d-TRA (50 patients) and in the second arm via conventional TRA group (50 patients).

Results

Technically, there were highly statistically significant differences between the two arms in favor of TRA regarding procedural success, number of punctures taken, Access time, Total procedural time, vasodilator used, and crossover to another access site; meanwhile safety profile parameters have showed statistically significant differences in favor of d-TRA regarding post-operative hematoma, AV fistula, post-operative pain and compression time, and there were no statistically significant differences regarding RAO although it occurred more in TRA group.

Conclusions

In the realm of cardiac intervention, the distal radial approach is a promising technique. When compared to TRA, we found it to be a viable and safe method for coronary angiography and interventions and it could be a real option for the interventionists in the near future, with a lower risk of radial artery blockage and no significant differences in wrist hematoma and radial artery spasm. The success rate of d-TRA is proportional to the steepness of the operator's learning curve and the quality of the examples chosen.

Safety of ultrasound-guided distal radial artery access for abdominopelvic transarterial interventions: a prospective study

PURPOSE

We aimed to evaluate ultrasound-guided distal radial artery (DRA) access to perform abdominopelvic endovascular procedures.

METHODS

A prospective, observational study was carried out in a single center between December 2017 and February 2019. Forty-two abdominopelvic endovascular procedures were performed by the same operator in 37 patients with DRA access using a 5 F sheath. Most patients were male (67.6%) with a mean age of 62.0±11.4 years (age range, 27.6-82.8 years). Patient characteristics, including Barbeau's test classification, radial and ulnar sizes and technical success, were evaluated. Patients with a DRA smaller than 1.7 mm could not be safely punctured and were not included.

RESULTS

Procedures included chemoembolization of hepatocellular carcinoma in 35 cases (83.3%), embolization of hepatic metastasis in neuroendocrine tumors in 4 cases (9.5%) and other embolization procedures in 3 cases (7.1%). The mean diameters of the DRA, proximal radial artery and proximal ulnar artery were 2.31, 2.63, and 2.09 mm, respectively. Out of 42 DRA puncture attempts, 97.6% (41/42) were successfully performed. There were no postoperative complications related to the access site, such as pain, palsy, paresthesia, occlusion, finger ischemia, bleeding, hematoma, and pseudoaneurysm. Transient forearm discomfort was reported in 7.1% of patients (3/42); one occurrence was associated with kinking rectification, and two occurrences were attributed to small arteries and/or vasospasm.

CONCLUSION

Ultrasound-guided DRA access seems to be feasible and safe to perform in abdominopelvic endovascular procedures in patients with a DRA considered amenable to be safely punctured, with high technical success rates.

Comparison of Distal Radial, Proximal Radial, and Femoral Access in Patients with ST-Elevation Myocardial Infarction

Recent studies have indicated that distal radial access (DRA) is feasible in patients undergoing percutaneous coronary intervention (PCI). The present study aimed to compare DRA, proximal radial access (PRA), and femoral access (FA) in patients with ST-elevation myocardial infarction (STEMI) undergoing PCI. Data were analyzed for 109 patients with STEMI treated via primary PCI from March 2020 to May 2021. The success rate of DRA was 83.3% (35/42), including seven cases of failed puncture (puncture failure = 5, severe radial artery spasm = 2). Primary PCI via the DRA was successful in all 35 patients. After classifying the patients requiring crossover into a separate group, the percentage of the puncture time in the door-to-wiring time was 2.7% [2.2–4.3], 3.3% [2.3–4.0], 2.6% [1.2–4.9], and 27.0% [13.5–29.3] in the DRA (n = 35), PRA (n = 24), FA (n = 26), and crossover (n = 9) groups, respectively (p < 0.01). Only two local hematomas (≤5 cm) occurred in the DRA group, while one patient in the FA group required surgical treatment and a transfusion for an access-site vascular injury. When performed by an experienced operator, DRA may represent a feasible alternative to other access routes in select patients with STEMI undergoing PCI, such as those with a high risk of bleeding.

The learning curve of the distal radial access for coronary intervention

Recently, coronary angiography (CAG) and percutaneous coronary intervention (PCI) via the distal radial access (DRA), are gaining attention owing to fewer complications. Despite the advantages of the DRA, there is difficulty to initiate this new vascular approach. The data from 1000 patients who underwent CAG and PCI via the DRA by a single experienced radial operator were retrospectively analyzed. The primary outcome was the success rate of the DRA per 100 cases. Moreover, the predictors of the failed DRA were analyzed. Overall, 952 (95.2%) of the total 1,000 patients underwent a successful DRA. After experiencing 200 cases, the DRA success rate was well maintained at > 94%, and there was no difference in success rate per 100 cases (P_trend = 0.216). The predictors of failure were female sex [odds ratio (OR) 1.84, 95% confidence interval (CI) 1.01–3.39, P = 0.049] and systolic blood pressure (SBP) of < 120 mmHg (OR 1.87, 95% CI 1.04–3.36, P = 0.036). For achieving a stable DRA with the success rate of > 94%, 200 procedures would be needed. Moreover, this new approach could fail in women and patients with low SBP.

Trial registration: https://cris.nih.go.kr/cris/index/index.do (Unique identifier: KCT0005349).

Efficacy and safety of distal radial approach for cardiac catheterization: A systematic review and meta-analysis

BACKGROUND

The traditional radial approach (RA) is recommended as the standard method for coronary angiography (CAG), while a distal RA (DRA) has been recently used for CAG.

AIM

To assess the efficacy and safety of the DRA vs RA during CAG.

METHODS

The following databases were searched through December 2020: MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the World Health Organization International Clinical Trials Platform Search Portal, and ClinicalTrials.gov. Individual randomized-controlled trials for adult patients undergoing cardiac catheterization were included. The primary outcomes were the successful cannulation rate and the incidence of radial artery spasm (RAS) and radial artery occlusion (RAO). Study selection, data abstraction and quality assessment were independently performed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Three randomized control trials and 13 registered trials were identified. The two approaches showed similar successful cannulation rates [risk ratio (RR) 0.90, 95% confidence interval (CI): 0.72-1.13]. The DRA did not decrease RAS (RR 0.43, 95%CI: 0.08-2.49) and RAO (RR 0.48, 95%CI: 0.18-1.29). Patients with the DRA had a shorter hemostasis time in comparison to those with the RA (mean difference -6.64, 95%CI: -10.37 to -2.90). The evidence of certainty was low.

CONCLUSION

For CAG, the DRA would be safer than the RA with comparable cannulation rates. Given the limited data, additional research, including studies with standard protocols, is necessary.

Feasibility and Safety of the Left Distal Radial Approach in Percutaneous Coronary Intervention for Bifurcation Lesions

Recently, the left distal radial approach (DRA) for percutaneous coronary intervention (PCI) has been shown to be a feasible option, but there are limited data regarding the feasibility of performing bifurcation PCI via the left DRA. Therefore, this study aimed to describe our experience with the contemporary left DRA to perform PCI of bifurcation lesions. Between December 2017 and December 2019, we identified 106 patients treated with bifurcation PCI via the left DRA. We evaluated the success rate of PCI, access-site complications including major bleeding requiring surgery or transfusion, hematoma, distal and forearm radial artery occlusion, and 30-day mortality. Eleven patients (10.4%) treated with left main bifurcation and true bifurcations accounted for 39.6% of cases, with the left anterior descending artery/diagonal branch being the most frequent bifurcation site (57.5%, 61/106). PCI was performed using a 6-French guiding catheter in 101 (95.3%) cases. Successful PCI for bifurcation lesions via the left DRA was achieved in all 106 patients without access-site cross-over. There was no major bleeding, distal and forearm radial artery occlusion, forearm hematoma, or mortality at 30 days. The left DRA is a safe and feasible alternative access site for bifurcation PCI in selected patients.

Left distal radial artery approach versus conventional radial artery for coronary angiography

We aimed to evaluate feasibility, contrast utilization and complications of trans-radial approach comparing the left distal trans-radial artery (lt. dTRA) access versus conventional right trans-radial artery (rt. TRA) access in coronary angiography. Subjects and Methods: This study was conducted on (100) patients who underwent coronary angiography (50 patients via lt. dTRA & 50 patients via rt. TRA) and was performed in the department of cardiology, Benha University Hospital. All patients performed ECG, echocardiography, arterial doppler pre and post procedures.

Access-site hematoma in distal and conventional transradial access: a randomized trial

BACKGROUND

Distal transradial access (dTRA) has been recently proposed as an innovative access for coronary procedures and a valuable alternative to conventional transradial access (cTRA). The aim of this study was to assess the safety of dTRA versus cTRA in patients undergoing percutaneous coronary angiography and intervention.

METHODS

In this single-center randomized trial, consecutive patients admitted for stable cardiac condition or acute coronary syndrome (ACS) were assigned to dTRA or cTRA. The primary endpoint was an early discharge after transradial stenting of coronary arteries (EASY) grade ≥II access-site hematoma (ASH). Vascular access failure, radial artery occlusion (RAO) at hospital discharge , 30-day rates of death, myocardial infarction, stroke and bleeding not related to coronary artery bypass grafting were considered as secondary endpoints.

RESULTS

A total of 204 patients were included and randomized to dTRA (n=100) or cTRA (n=104). The two populations were similar, except for a higher percentage of ACS in the dTRA than in the cTRA group (38% versus 24%, P=0.022). The rate of EASY grade ≥II ASH was lower in dTRA than in cTRA patients, but the difference was not statistically significant (4% versus 8.4%, respectively, P=0.25). Vascular access failure was more frequent in dTRA patients than in cTRA patients (34% versus 8.7%, P<0.0001). We detected no case of RAO at hospital discharge and similar rates of 30-day adverse events in both groups.

CONCLUSIONS

DTRA is safe and feasible. When compared to cTRA, dTRA is technically more demanding and limited by more frequent crossover to an alternative vascular access.

Manual versus mechanical compression hemostasis approach after coronary angiography via snuffbox access

OBJECTIVE

Distal radial artery access or trans-snuffbox access (TSA) is a novel, safe, and feasible technique for coronary artery interventions wherein its vascular hemostasis is still concerned. So, this study aimed to compare two homeostasis methods comprising manual and mechanical compression approaches in patients undergoing coronary angiography (CAG) via TSA.

METHODS

In a prospective nonrandomized clinical trial, a total of 80 patients undergoing diagnostic CAG by TSA were divided into two equal groups: manual compression and mechanical compression (using radial TR band), the main end point of which was primary hemostasis time. Other variables were patient satisfaction, puncture site pain severity, hospitalization time, and local neurovascular complication during the 30-day follow-up.

RESULTS

The mean age of the patients was 57.1±8.0 years, with 40 of them (54.1%) being male. The primary hemostasis time was significantly shorter in the manual compression approach [15.0±5.9 minutes with median 15 (9-20)] than in the TR band group [25.7±4.9 minutes with median 25 (20-30)] (p<0.001). No significant difference was noted in the patient's satisfaction and puncture site pain severity as well as hospitalization time between the two methods (p>0.050). The neurovascular complication, including hematoma, numbness, and dRA occlusion, rates had also no significant difference between the two groups (p>0.050).

CONCLUSION

The manual compression approach on the puncture site reduces hemostasis time in patients undergoing CAG via TSA when compared with the mechanical compression method.

Feasibility of primary percutaneous coronary intervention via the distal radial approach in patients with ST-elevation myocardial infarction

BACKGROUND/AIMS

Recently, distal radial approach (DRA), called as snuffbox approach, has gained the interest of interventional cardiologists, but there is a lack of data about the feasibility of DRA as an alternative route for primary percutaneous coronary intervention (PCI).

METHODS

A total of 138 patients presenting with ST-elevation myocardial infarction (STEMI) in whom primary PCI via the DRA was attempted at three hospitals from October 2017 to September 2019 were analyzed.

RESULTS

The success rate of snuffbox puncture in the setting of STEMI was 92.8% (128/138). Successful primary PCI via the DRA was achieved in all 128 patients. The snuffbox puncture time, defined as the time interval from local anesthesia induction to successful sheath cannulation, was 2.7 ± 1.6 minutes, and snuffbox puncture was performed within 5 minutes in 95.3% of patients. Moreover, the percentage of the puncture time in the door-to-balloon time was 3.3%. The left DRA was selected in 103 patients (80.5%), and primary PCI via the DRA was performed using a 6-Fr guiding catheter in 125 patients (97.7%). There was no major bleeding; however, there were four cases (3.1%) of access-site complications, including three cases of local hematoma (≤ 5 cm diameter) and one case of local numbness, which improved 3 months later.

CONCLUSION

In the setting of STEMI, the DRA could be a feasible alternative access route for primary PCI.

Feasibility and Safety of the Distal Transradial Artery for Coronary Diagnostic or Interventional Catheterization

Background

This prospective study compared the success rate and safety of a distal transradial artery (dTRA) approach to that of the conventional transradial artery (TRA) for coronary angiography or percutaneous coronary intervention.

Methods

From January 2019 to April 2020, nine hundred consecutive patients (height < 190 cm) scheduled for coronary angiography or percutaneous coronary interventions were randomly and equally assigned to receive either dTRA or conventional TRA catheterization.

Results

Successful access was achieved in 96.00% and 96.67% of the dTRA and conventional TRA groups, respectively (P=0.814). Compared with the TRA group, patients in the dTRA experienced significantly less hemostatic band removal time (150.5 ± 50.5 cf. 210.6 ± 60.5 min, P=0.032); minor bleeding of the access site (2.44% cf. 6.44%, P=0.038); hemostatic band cost (USD; 0.1 cf. 59.4, P=0); and postprocedural radial artery occlusion (1.56% cf. 3.78%, P=0.035). A lower body mass index was a higher risk factor for dTRA access failure (odds ratio = 0.79, P=0.024), with a cutoff of 22.04 kg/m².

Conclusion

Compared to conventional TRA, dTRA had a comparable high success rate, with fewer associated complications. Clinicians should use the dTRA with caution in patients with low body mass index.

Distal radial approach: a review on achieving a high success rate

INTRODUCTION

The transradial approach is the standard for percutaneous coronary intervention (PCI). Moreover, to lead to the evolution of PCI, a new approach site was developed, namely the distal radial approach (dRA).

ANATOMY AND VESSEL DIAMETER

The vessel diameter of the distal radial artery is smaller than that of the forearm radial artery; hence, use of 1 Fr size or a sheath with a thinner outer diameter is recommended. Ultrasound examination before the procedure provides useful information on this matter.

PUNCTURE

There are two approaches to puncture: proximal site puncture of the distal radial artery and distal site puncture. Based on anatomical characteristics, the puncture angle is large on the former and small on the latter. Although a learning curve for the dRA puncture is needed, the use of ultrasound facilitates the process.

HEMOSTASIS

Using a hemostatic device dedicated to the dRA simplifies observation after PCI. Hemostatic devices for the conventional radial approach or simple bandage with an elastic band can be useful. Usually, less hemostasis time is needed for the dRA compared with the conventional radial approach.

SUCCESS RATE

Studies have shown high success rates of the dRA (approximately 88-99.5%).

ADVANTAGES AND DISADVANTAGES

Advantages of the dRA are patient comfort, short hemostasis time, less restraint for the patients after PCI, and easy observation at the ward. Disadvantages are the learning curve required for the puncture and the small diameter of the distal radial artery.

CONCLUSION

The dRA is a new approach site for PCI. Further research is warranted for the selection of suitable patients to undergo PCI through the dRA.

Distal radial artery (snuffbox) access for carotid artery stenting - Technical pearls and procedural set-up

PURPOSE

To report use of distal radial artery (dRA) access for carotid artery stenting (CAS) and to discuss procedural setup and technical considerations for a successful intervention.

METHODS

A retrospective review of our prospective neurointerventional database of CAS was conducted between May 2019 and March 2020. All CAS cases via dRA in the anatomical snuffbox were identified. Patient demographics, clinical information, procedural and radiographic data was collected.

RESULTS

22 CAS procedures in 20 patients via dRA were identified. Patients' mean age was 69.4 years (range 53-87 years). 3 patients were female. Mean radial artery diameter was 2.1 mm (range 1.6-2.8 mm). dRA access was achieved in all cases. Conversion to femoral access was required in 2 cases (9.1%) due to persistent radial artery vasospasm resulting in patient discomfort despite multiple additional doses of intraarterial vasodilators and added intravenous sedation as well as tortuous vessel anatomy and limited support of the catheters in a type 3 aortic arch for left CAS.

CONCLUSION

Our preliminary experience with dRA access for CAS suggests this approach to be feasible and safe for patients. Technical considerations are important and preprocedural planning is necessary for a successful intervention. Catheter systems and devices specifically designed for radial access are needed to enable more interventionalists to safely perform neurointerventional procedures via wrist access.

Distal radial artery (snuffbox) access for carotid artery stenting - Technical pearls and procedural set-up

PURPOSE

To report use of distal radial artery (dRA) access for carotid artery stenting (CAS) and to discuss procedural setup and technical considerations for a successful intervention.

METHODS

A retrospective review of our prospective neurointerventional database of CAS was conducted between May 2019 and March 2020. All CAS cases via dRA in the anatomical snuffbox were identified. Patient demographics, clinical information, procedural and radiographic data was collected.

RESULTS

22 CAS procedures in 20 patients via dRA were identified. Patients' mean age was 69.4 years (range 53-87 years). 3 patients were female. Mean radial artery diameter was 2.1 mm (range 1.6-2.8 mm). dRA access was achieved in all cases. Conversion to femoral access was required in 2 cases (9.1%) due to persistent radial artery vasospasm resulting in patient discomfort despite multiple additional doses of intraarterial vasodilators and added intravenous sedation as well as tortuous vessel anatomy and limited support of the catheters in a type 3 aortic arch for left CAS.

CONCLUSION

Our preliminary experience with dRA access for CAS suggests this approach to be feasible and safe for patients. Technical considerations are important and preprocedural planning is necessary for a successful intervention. Catheter systems and devices specifically designed for radial access are needed to enable more interventionalists to safely perform neurointerventional procedures via wrist access.

Left Distal Radial Artery Access Site in Primary Percutaneous Coronary Intervention: Is It Safe?

Background:

Left distal radial artery access site has emerged as a new technique for coronary angiography procedures.

Aims:

We aimed at assessing its applicability as an alternative way for primary percutaneous coronary interventions in ST-elevation myocardial infarction.

Study Design:

Retrospective observational cohort study.

Methods:

Left distal radial artery was used as an access site in 30 consecutive ST-elevation myocardial infarction patients for primary coronary intervention. It was used by experienced operators who were unaware of the study. All patients had a prominent pulse in their left forearm and distal radial artery. Each patient’s left arm was gently bent into his/her right groin with comfortable position of the hand. The operator/s stood at the right side of the patient where both could make the arterial puncture. Demographic features and complications were recorded during the hospital stay.

Results:

Mean age of patients was 58 years with a male gender predominance of 87%. Fifteen patients were diagnosed of Inferior elevation myocardial infarction, 14 patients of Anterior, and one of Lateral elevation myocardial infarction. The most common culprit artery was the left anterior descending coronary artery (14 patients). Six patients were in KILLIP class II on admission and only one with Anterior elevation myocardial infarction was in severe pulmonary edema (KILLIP III) during intervention. All the procedures were successfully contemplated with 6 French Judkins catheters. Brachial spasm occurred in one patient which was resolved with intra-arterial nitrate. Transfemoral approach was changed to left distal radial access in 4 patients due to severe bilateral iliac artery disease. Mean puncture time was 37.36 seconds. There was no radial occlusion, hematoma, hand neurologic deficit or bleeding. Patients were discharged on an average duration of 4.2 days.

Conclusion:

Left distal radial artery can be used as an alternative safe and feasible access site for successful primary coronary interventions provided that it is performed by experienced operators.

Distal transradial access: a review of the feasibility and safety in cardiovascular angiography and intervention

BACKGROUND

Transradial access (TRA) has been considered as the default choice in cardiac catheterization. Although infrequent, vascular complications of this approach remain. Recently, the distal transradial approach (dTRA) in cardiac catheterization was reported by interventionalists.

METHODS

We retrieved the relevant literatures and reviewed the safety and feasibility of this novel approach in cardiac catheterization.

RESULTS

The dTRA for cardiac intervention has superior safety and satisfaction. As a novel approach for cardiac catheterization, access related complications should also be considered by operators, such as RAO, radial spasm, bleeding and haematoma, and injury of the superficial branch of the radial nerve.

CONCLUSIONS

The dTRA in cardiovascular angiography and intervention was safe and feasible.

Left distal radial access in patients with arteria lusoria: insights for cerebral angiography and interventions

BACKGROUND

The transradial approach (TRA) is frequently used for neurointerventional procedures as it is safer, improves patient comfort, and decreases costs and procedural time in comparison with the transfemoral approach (TFA). Patients with arteria lusoria, or an aberrant right subclavian artery (ARSA), provide a unique challenge for cerebral angiography and interventions when using the TRA.

OBJECTIVE

To examine the hypothesis that the extreme angulation encountered while accessing the great vessels from the right TRA could be overcome by reversing the approach to the left distal TRA (dTRA).

METHODS

A prospectively maintained database of transradial neurointerventional cases since 2018 was searched. Six cases from 850 were identified, in which the left dTRA was used. Three cases were for patients with an ARSA. For the three cases of interest, patient history, pathology, imaging, and access techniques were reviewed.

RESULTS

Two diagnostic cerebral angiography cases and one intervention were successfully performed through a left dTRA.

CONCLUSIONS

Proper positioning of the left wrist and familiarity with forming the Simmons catheter can overcome this anatomical challenge. This technique and results further demonstrate that the left distal radial artery is a feasible access site for catheterization of bilateral carotid, left vertebral, and right subclavian arteries for patients with an ARSA.

An observational comparison of distal radial and traditional radial approaches for coronary angiography

Background

Several studies have recently reported regarding feasibility and safety of distal transradial access (d-TRA) in the anatomical snuff-box (ASB); however, literature comparing it with the conventional TRA at the wrist (w-TRA) is sparse. This study compares the technical efficiency and safety of ASB and wrist approaches for TRA for coronary angiography (CAG) and evaluates the radial artery (RA) anatomy at these sites.

Methods

Two hundred consecutive patients undergoing CAG via w-TRA or d-TRA (100 in each group) were investigated. The primary endpoint was comparison of procedural efficiency of the two methods, defined as CAG completion from the intended access site. The secondary endpoints assessed d-TRA approach in terms of achievement of successful cannulation, arterial puncture, access time (AT), and total procedure time (TPT) in comparison with the conventional method. Safety endpoints included radiation parameters and complications. Furthermore, in 112 normal adults, RA anatomy was assessed at wrist and at ASB.

Results

In d-TRA group, 77% patients achieved primary endpoint compared with 93% in w-TRA group (p = 0.004). The success of arterial puncture was comparable for d-TRA and w-TRA (93% and 99%, respectively; p = 0.065), but the cannulation rate was lower for d-TRA. Safety endpoints were similar in both the groups. AT and TPT were longer for d-TRA.

Conclusions

The ASB approach for CAG lowers the success rate and prolongs AT and TPT. The RA at ASB is smaller, has a curved course, and more anatomical variations than the RA at the wrist.

Distal Radial Artery Access: The Future of Cardiovascular Intervention

Access sites for coronary intervention have been changing over the last several decades, from the femoral artery to the radial artery and then to the distal radial artery. Distal radial access, which was first used in 2017 and is still not recommended by the guidelines, shows a higher success rate and less complications than other sites; therefore, it might be the future for cardiovascular intervention. In this study, we reviewed almost all of the articles that are related to the distal radial access, from 2017 to present, and summarized the technique, success rate, advantages, disadvantages, and noncardiac use of this 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.

Distal radial access in the anatomical snuffbox for neurointerventions: a feasibility, safety, and proof-of-concept study

PURPOSE

To report the first use of distal radial artery (dRA) access for a variety of neurointerventions and to demonstrate the safety and feasibility of this approach.

METHODS

A retrospective review of our prospective neurointerventional database of endovascular interventions was conducted and, between May and October 2019, all patients in whom the intervention was performed via dRA in the anatomical snuffbox were identified. Patient demographics, clinical information, procedural and radiographic data were collected.

RESULTS

48 patients with a mean age of 64.4 years (range 35-84 years) were included. 27 patients were female. dRA access was achieved in all cases. Conversion to femoral access was required in five cases (10.4%) due to tortuous vessel anatomy and limited support of the catheters in the aortic arch. Interventions performed included aneurysm treatment (with flow diverters, Woven EndoBridge device placement, coiling or stent-assisted coiling), arteriovenous malformation and dural arteriovenous fistula embolization, carotid artery stentings, stroke thrombectomy, thrombolysis for central retinal artery occlusion, intracranial stenting, middle meningeal artery embolization, vasospasm treatment, and spinal angiography with embolization. Radial artery vasospasm was seen in two cases and successfully treated with antispasmolytic medication. No symptomatic radial artery occlusion or ischemic event was observed.

CONCLUSION

dRA access is safe and effective for a variety of neurointerventions. Our preliminary experience with this approach is very promising and shows high patient satisfaction.

Evaluation of radial artery endothelial functions in transradial coronary angiography according to different radial access sites

OBJECTIVE

Radial endothelial dysfunction may occur after transradial coronary angiography (CAG). This study aimed to make a comparative evaluation of the radial endothelial functions before and after catheterization between three different radial access sites: left radial (LR) artery, left distal radial (LDR) artery, and right radial (RR) artery.

METHODS

Seventy patients scheduled for elective transradial CAG and intervention from September 6, 2017 to March 6, 2018 were consecutively enrolled. Radial artery endothelial functions of the catheterization arm were measured by flow-mediated vasodilation (FMD) upon admission, at 24 hours, and 2 months following the procedure.

RESULTS

LR access was used in 17 patients, whereas the LDR and the RR access were used in 27 and 26 patients, respectively. Basal radial diameters and FMD median values measured on the intervention arm were found to be similar between groups (LR 3.04±0.29 mm, 13.33%; LDR 2.79±0.31 mm; 13.64%; RR 2.74±0.29 mm; 12.52%, p=0.952). The radial vasodilation percentage change expressed as median decreased in all groups 24 hours after the procedure; however, the one with the LDR access was found to be significantly higher than with the LR (9.7% vs. 6.25% p=0.013) and the RR access (9.7% vs. 3.39 p<0.001). A partial recovery of endothelial functions was seen at 2 months after the procedure, approximating to basal values (11.11%; 12%; 10.62%, p=0.079, respectively).

CONCLUSION

Radial artery functions deteriorate early after transradial catheterization. The LDR access seems safer than the other conventional radial access sites in terms of preservation of radial endothelial functions.

Distal radial artery access in the anatomical snuffbox for coronary angiography and intervention: A single center experience

BACKGROUND

To explore the feasibility and safety of coronary angiography (CAG) and percutaneous coronary intervention (PCI) via the distal radial artery in the anatomical snuffbox.

METHODS

Ninety two patients who underwent CAG or PCI through distal radial artery access at The Second Affiliated Hospital of Zhejiang Chinese Medical University from September 2017 to March 2018 were included in our study. We collected baseline characteristics, number, and duration of arterial punctures, procedural success rate, postoperative compression time, the numerical rating scale (NRS) scores at 3 hours after procedure, complications, hospitalization duration.

RESULTS

The mean age was 69 ± 11years (44-92 years), and there were 57 males (62.0%). The diameter of the right distal radial artery and the more proximal right radial artery were 0.171 ± 0.05 cm, 0.213 ± 0.06 cm, respectively. On average, the number of puncture attempts was 1.52 ± 0.81, access time was 2.3 ± 1.78 minutes (0.33 - 8.72 minutes), access success was 95.7%, the postoperative compression time was 3.41 ± 0.76 hours (2-6 hours), the NRS scores at 3 hours was 1.53 ± 0.72 (1-4), and the mean hospitalization duration was 7.13 ± 4.02 days. Four patients underwent left distal radial artery access and 88 patients underwent right distal radial artery access. There were 3 local hematomas after procedure and 2 patients had vasospasm. There were no cases of major bleeding, arteriovenous fistula, radial artery occlusion, or hand numbness.

CONCLUSION

Cardiac catheterization through the distal radial artery in the snuffbox is safe and feasible. The right distal radial artery access can be routinely carried out.

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 Transradial Access in the Anatomic Snuffbox for Diagnostic Cerebral Angiography

The aim of this study was to describe the feasibility, technique, and safety of distal transradial access in the anatomic snuffbox for diagnostic cerebral angiography. A retrospective review of diagnostic cerebral angiograms obtained during a 6-month period with distal transradial access was performed. Thirty-four successful procedures were performed via distal transradial access. There were 4 failed attempts. This single-center experience using distal transradial access suggests that this technique is safe and effective.

Very distal transradial approach (VITRO) for coronary interventions

Introduction

Radial access is a standard approach for coronary interventions. However, it carries some risk of local or long-term complications such as hematoma or radial artery occlusion.

Aim

To assess the feasibility of a very distal left and right transradial approach (VITRO) for coronary interventions.

Material and methods

Three hundred and twenty consecutive patients were submitted to diagnostic or therapeutic coronary interventions. In 102 patients the distal radial artery was not palpable or the pulse was too weak. In 218 selected patients (142 male, 76 female, age: 69 ±11 years) we decided to perform a distal transradial approach.

Results

The VITRO access was suitable in 195 patients with a success rate of 89.4%. In 9 patients arterial puncture failed, while in 14 others despite successful arterial puncture the wire could not be advanced towards the forearm part of the radial artery. Not only elective diagnostic angiographies were performed with VITRO but also urgent ad hoc coronary interventions in subjects with unstable angina or NSTEMI (48 subjects; 24.3%). Moreover, this very distal approach allowed 11 rotablations and 11 FFR/iFR examinations to be performed in 22 patients. No major bleeding, requiring prolonged hospital stay, surgery or transfusion occurred. One patient on oral anticoagulation with DAPT had conservatively managed minor forearm bleeding.

Conclusions

Very distal radial artery access is feasible, safe and comfortable in 60% of patients referred for elective or urgent coronary arteries angiography, or coronary interventions.

Feasibility Study of "Snuffbox" Radial Access for Visceral Interventions

"Snuffbox" radial access entails sheath insertion into the dorsal branch of the radial artery within the so-called anatomic snuffbox. The purpose of this report is to describe the technique and early experience in 50 visceral interventional procedures performed in 31 patients, which included liver embolotherapy, visceral arterial stent insertion, aneurysm embolization, and emergency embolization. In all cases, the procedures were successfully completed by using the snuffbox access, with a single case of asymptomatic pseudoaneurysm as the only access-related complication. Early experience showed that snuffbox radial access is technically feasible and represents a viable alternative to conventional radial access for visceral intervention procedures.

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.

Left distal trans-radial access facilitates earlier discharge post-coronary angiography

AIMS

In 2017, Kiemeneij published a paper on distal trans-radial artery access for coronary angiography in 62 patients. This paper proposed several advantages to this method. Since this paper was published, several other papers have been published describing this technique, with less than 200 cases in total described. We performed a non randomized control study of left distal trans-radial access in patients undergoing coronary angiography in our center.

METHODS

We prospectively identified patients presenting for coronary angiography to our center for enrolment in this study. We recruited 94 patients (47 ldTRA, 47 age and sex matched controls). Pre-defined endpoints for the study were as follows: time until radial compression device (RCD) removal, procedural time, radiation dose, fluoroscopy time, and contrast dose.

RESULTS

Patient and procedural characteristics did not differ significantly between the two groups. With regard to our primary endpoint, patients undergoing ldTRA required, on average, 69 min less time until removal of the RCD (167.8 ± 30 vs 236.6 ± 63.9 min, P < 0.0001). Procedural length did not vary between groups (28.95 ± 5.89 vs 29.76 ± 8.16 min, P = 0.5824). Similarly, there was no statistically significant difference in radiation dose area product (5032.66 ± 2740 vs 4826 ± 2796 Gy/cm² , P = 0.7191), contrast dose (82.93 ± 23 vs 92.1 ± 33 mL, P = 0.1215), and fluoroscopy time between the two groups (5.41 ± 3.42 vs 4.82 ± 2.97 min, P = 0.3742).

CONCLUSIONS

Our study confirms that ldTRA is a feasible technique for diagnostic coronary angiography in a modern cardiac catheterization laboratory. It results in decreased post-procedure radial artery compression time without increasing procedural time or radiation dose.

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

BACKGROUND AND OBJECTIVES

Feasibility of coronary angiography (CAG) and percutaneous coronary intervention (PCI) via left snuffbox approach is still concerned. We aimed to investigate efficacy and safety of the left snuffbox approach for CAG and PCI.

METHODS

Left snuffbox approach was tried in 150 patients who planned to perform CAG or PCI for suspected myocardial ischemia between 1 November 2017 and 31 March 2018.

RESULTS

Success rate of radial artery (RA) cannulation via snuffbox approach was 88.0% (n=132). Among 132 individuals, 58 (43.9%) acute coronary syndrome (ACS) patients were included. The diameter of snuffbox RA was significantly smaller than conventional RA (2.57 mm vs. 2.72 mm, p<0.001) from quantitative computed angiography of 101 patients. However, CAG via snuffbox approach by 6 French sheath was successfully performed in all 132 patients. In addition, there was significant correlation between the snuffbox and conventional RA diameter (r=0.856, p<0.001). In 42 PCI cases, including 25 patients with acute myocardial infarction (AMI), the success rate of PCI via snuffbox approach was 97.6% (n=41). Intravascular imaging-guided PCI was performed in 8 (19.5%) patients and multi-vessel PCI in 4 (9.8%) cases. Regarding vascular complication, forearm swelling with bruising, not requiring surgery or transfusion, occurred in 2 (4.9%) PCI cases.

CONCLUSIONS

Left snuffbox approach is suitable for CAG and PCI compared with the conventional radial approach.