Distal versus proximal radial access in coronary angiography: a meta-analysis.

BACKGROUND: Distal radial access (DRA) represents a promising alternative to conventional proximal radial access (PRA) for coronary angiography. Substantial advantages regarding safety and efficacy have been suggested for DRA, but the ideal access route remains controversial. AIMS: The aim of this study was to compare safety, efficacy and feasibility of DRA to PRA. METHODS: National Library of Medicine PubMed, Web of Science, clinicaltrials.gov and Cochrane Library were systematically searched for randomized controlled trials and registry studies comparing DRA and PRA that were published between January 1, 2017 and April, 2024. Primary endpoint was the rate of radial artery occlusion (RAO). Secondary endpoints were access failure, access time, procedure time, arterial spasm, hematoma, and hemostasis time. Data extraction was performed by two independent investigators. Relative risks were aggregated using a random effects model. We applied meta-analytic regression to assess study characteristic variables as possible moderators of the study effects. RESULTS: 44 studies with a total of 21,081 patients were included. We found a significantly lower rate of RAO after DRA (DRA 1.28%, PRA 4.76%, p < .001) with a 2.92 times lower risk compared to the proximal approach (Log Risk Ratio = -1.07, p < .001). Conversely, the risk for access failure was 2.42 times higher for DRA compared to PRA (Log Risk Ratio = 0.88, p < .001). CONCLUSION: In this largest meta-analysis to date, we were able to show that rates of RAO are reduced with DRA compared to conventional PRA. This suggests DRA is a safe alternative to PRA.

The distal radial artery: Versatile vascular access for transcatheter interventions.

Conventional transradial access has been established as the gold standard for invasive coronary angiography and percutaneous interventions by the current European and American guidelines. The distal or snuffbox radial artery access represents an alternative transradial access site that allows radial sheath insertion with the patient's hand pronated. Firstly described 40 years ago, it exploded in popularity only recently. Promising additional benefits, the distal radial access is increasingly being adopted in various types of percutaneous interventions, being preferred by many interventional cardiologists and radiologists for its reduced vascular complications and time to hemostasis, and improvement of patient and operator comfort. Other centers consider it a fad, waiting for solid clear evidence and benefits. The evidence is dynamic and discrepant, depending on the center, the operator, and how it was collected (randomized controlled vs observational studies). Another essential aspect raised by "skeptics" was whether distal radial access, by its smaller diameter and more angled course, can support all types of interventions. The aim of this review is to gather all the scenarios where distal radial access has been utilized and to conclude whether this vascular access is feasible across all transcatheter interventions.

Distal Versus Proximal Radial Artery Access for Cardiac Catheterization: 1-Year Outcomes.

Proximal radial artery (PRA) access for cardiac catheterization is safe but can jeopardize subsequent use of the artery because of occlusion. Distal radial artery (DRA) access in the anatomical snuffbox preserves the RA but safety and potential detrimental effects on hand function are unknown. We aimed to assess hand function and complications after DRA and PRA. In this single-center trial, 300 patients were randomly allocated 1:1 to cardiac catheterization through DRA or PRA. The primary end point of change in hand function from baseline to 1 year was a composite of the Quick Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, hand grip test, and thumb-forefinger pinch test. The secondary end points included access feasibility and complications. Of 216 patients with 1-year completed follow-up, 112 were randomly allocated to DRA and 104 to PRA, with balanced demographics and procedural characteristics. Both groups had similar access site bleeding rates (DRA 0% vs PRA 1.4%, p = 0.25). Radial artery occlusion occurred in 1 PRA patient versus 2 in DRA. There was no significant difference in change of hand function, median (interquartile range) hand grip (DRA 0.7 [-3 to 4.5] vs PRA 1.3 [-2 to 4.3] kg, p = 0.57), pinch grip (DRA -0.1 [-1.1 to 1] vs PRA -0.3 [-1 to 0.7] kg, p = 0.66), and Quick DASH (DRA 0 [-6.6 to 2.3] vs PRA 0 [-4.6 to 2.9] points, p = 0.58). The composite of hand function was comparable between PRA and DRA. In conclusion, DRA is a safe strategy for cardiac catheterization, with a low complication rate. Compared with PRA, there is no increased risk of hand dysfunction or radial artery occlusion at 1 year.

Distal Versus Proximal Radial Arterial Access for Percutaneous Coronary Angiography and Intervention: Updated Meta-Analysis of Randomized Controlled Trials.

Radial artery occlusion (RAO) is a major impediment to reintervention in patients who underwent proximal transradial access (p-TRA) for coronary catheterization. Distal transradial access (d-TRA) at the level of snuffbox distal to the radial artery bifurcation is a novel alternative to p-TRA. We conducted an updated meta-analysis of all available randomized controlled trials (RCTs) to compare the incidence of RAO between p-TRA and d-TRA, along with access site-related complications. PubMed, Web of Science, and Google Scholar were searched for RCTs published since 2017 to October 2023 comparing d-TRA and p-TRA for coronary angiography and/or intervention. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals were calculated using the random-effects model for procedural and clinical outcomes for the 2 approaches. A total of 18 RCTs with 8,205 patients (d-TRA n = 4,096, p-TRA n = 4,109) were included. The risk of RAO (RR 0.31, 0.21 to 0.46, p ≤0.001) and time to hemostasis (minutes) (MD -51.18, -70.62 to -31.73, p <0.001) was significantly lower in the d-TRA group. Crossover rates (RR 2.39, 1.71 to 3.32, p <0.001), access time (minutes) (MD 0.93, 0.50 to 1.37, p <0.001), procedural pain (MD 0.46, 0.13 to 0.79, p = 0.006), and multiple puncture attempts (RR 2.13, 1.10 to 4.11, p = 0.03) were significantly higher in the d-TRA group. The use of d-TRA for coronary angiography and/or intervention is associated with a lower risk of RAO at the forearm and may preserve p-TRA site for reintervention in selective patients by reducing the incidence of RAO.

Distal Radial Access for Coronary Procedures in a Large Prospective Multicenter Registry: The KODRA Trial.

BACKGROUND: Distal radial access (DRA) as an alternative access route lacks evidence, despite its recent reputation. OBJECTIVES: The aim of this study was to evaluate the safety and feasibility of DRA on the basis of daily practice. METHODS: The KODRA (Korean Prospective Registry for Evaluating the Safety and Efficacy of Distal Radial Approach) trial was a prospective multicenter registry conducted at 14 hospitals between September 2019 and September 2021. The primary endpoints were the success rates of coronary angiography (CAG) and percutaneous coronary intervention (PCI). The secondary endpoints included successful distal radial artery puncture, access-site crossover, access site-related complications, bleeding events, and predictors of puncture failure. RESULTS: A total of 4,977 among 5,712 screened patients were recruited after the exclusion of 735 patients. The primary endpoints, the success rates of CAG and PCI via DRA, were 100% and 98.8%, respectively, among successful punctures of the distal radial artery (94.4%). Access-site crossover occurred in 333 patients (6.7%). The rates of distal radial artery occlusion and radial artery occlusion by palpation were 0.8% (36 of 4,340) and 0.8% (33 of 4,340) at 1-month follow-up. DRA-related bleeding events were observed in 3.3% of patients, without serious hematoma. Multilevel logistic regression analysis identified weak pulse (OR: 9.994; 95% CI: 7.252-13.774) and DRA experience <100 cases (OR: 2.187; 95% CI: 1.383-3.456) as predictors of puncture failure. CONCLUSIONS: In this large-scale prospective multicenter registry, DRA demonstrated high success rates of CAG and PCI, with a high rate of puncture success but low rates of distal radial artery occlusion, radial artery occlusion, bleeding events, and procedure-related complications. Weak pulse and DRA experience <100 cases were predictors of puncture failure. (Korean Prospective Registry for Evaluating the Safety and Efficacy of Distal Radial Approach [KODRA]; NCT04080700).

Distal radial access for neuroangiography and neurointerventions: systematic review and meta-analysis.

BACKGROUND: Many studies have shown that coronary angiography (CAG) and percutaneous coronary intervention (PCI) via distal radial access (DRA) are safe and effective. Safety and efficacy of neuroangiography and neurointerventions via DRA are unknown. PURPOSE: Search the literatures on neuroangiography and neurointerventions via DRA and conduct a systematic review and meta-analysis. METHODS: PubMed, Embase and Cochrane were searched from inception to November 10, 2022. After literature screening, data extraction and assessment of literature quality, random effects model was used for meta-analysis. RESULTS: A total of 236 literatures were retrieved, and 17 literatures including 1163 patients were finally included for meta-analysis.The pooled access success rate was 0.96 (95% confidence interval, 0.94-0.98), and the heterogeneity was obvious (I2 = 55.5%). The pooled access-related complications incidence rate was 0.03 (95% confidence interval, 0.02-0.05), and the heterogeneity was not obvious (I2 = 15.8%). CONCLUSION: Neuroangiography and neurointerventions via DRA may be safe and effective. DRA is an alternative access for neuroangiography and neurointerventions.

Efficacy and Safety of Distal Radial Access for Transcatheter Arterial Chemoembolization (TACE) of the Liver.

BACKGROUND: The distal radial artery has emerged as an alternative vascular-access site to conventional transfemoral and transradial approaches. The main advantage over the conventional transradial route is the reduced risk of radial artery occlusion, especially in those patients who, for various clinical reasons, have to undergo repeated endovascular procedures. This study aims to assess the efficacy and safety of distal radial access for transcatheter arterial chemoembolization of the liver. METHODS: This investigation is a single-center retrospective analysis of 42 consecutive patients who had undergone, from January 2018 to December 2022, transcatheter arterial chemoembolization of the liver with distal radial access for intermediate-stage hepatocellular carcinoma. Outcome data were compared with a retrospectively constituted control group of 40 patients undergoing drug-eluting beads-transcatheter arterial chemoembolization with femoral access. RESULTS: Technical success was achieved in all cases, with a 2.4% conversion rate for distal radial access. A superselective chemoembolization was performed in 35 (83.3%) cases of distal radial access. No episode of radial artery spasm or radial artery occlusion occurred. No significant differences in efficacy and safety were observed between the distal radial access group and the femoral access group. CONCLUSIONS: Distal radial access is effective, safe, and comparable to femoral access in patients undergoing transcatheter arterial chemoembolization of the liver.

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.

Early prevention of radial artery occlusion via distal transradial access for primary percutaneous coronary intervention.

Background: Conventional transradial access (TRA) has been the preferred access for coronary intervention. Recently, distal radial access (DRA) is introduced as an alternative choice to reduce radial artery occlusion (RAO) risk. The study sought to assess the impact of DRA on early RAO using Doppler ultrasound in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). Methods: This is a prospective, single-center, open-label randomized clinical trial in which patients with indications for primary PCI from January 2022 to September 2022 were assigned to DRA or TRA group with 100 cases in each group. The primary endpoint was the incidence of forearm RAO, evaluated by Doppler ultrasound before discharge. Results: The rate of access success was comparable between the DRA and TRA groups (98.0 vs. 94.0%, P = 0.279). Compared with the TRA group, longer puncture time was observed in the DRA group [2.4 (1.7-4.2) min vs. 1.7 (1.4-2.3) min; P < 0.001] whereas the door-to-wire time was not delayed in primary PCI [71 (54-88) min vs. 64 (56-82) min, P = 0.103]. Shorter hemostasis time was required in the DRA group [3.1 (2.7-3.3) h vs. 6.2 (5.9-6.4) h; P < 0.001]. Significant reduction of the incidence of forearm RAO was observed in the DRA group (2.0 vs. 9.0%, P = 0.030). Local hematomas ≤ 5 cm was similar in both groups (4.0 vs. 6.0%, P = 0.516), while those > 5 cm were significantly more frequent in the TRA group (0 vs. 6.0%, P = 0.029). Conclusion: Distal radial access is associated with a comparable lower incidence of forearm RAO, shorter hemostasis time, and lower rate of vascular complications compared to TRA in primary PCI. Systematic review registration: [https://www.chictr.org.cn], identifier [ChiCTR2200061841].

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.

Distal vs Conventional Radial Access for Coronary Angiography and/or Intervention: A Meta-Analysis of Randomized Trials.

BACKGROUND: Emerging evidence from randomized clinical trials (RCTs) comparing distal radial access (DRA) with conventional radial access (RA) is available. OBJECTIVES: The aim of this study was to provide a quantitative appraisal of the effects of DRA) vs conventional RA for coronary angiography with or without intervention. METHODS: The PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for RCT comparing DRA vs conventional RA for coronary angiography and/or intervention. Data were pooled by meta-analysis using a random-effects model. The primary endpoint was radial artery occlusion (RAO) at the longest available follow-up. RESULTS: Fourteen studies enrolling 6,208 participants were included. Compared with conventional RA, DRA was associated with a significant lower risk of RAO, either detected at latest follow-up (risk ratio [RR]: 0.36; 95% CI: 0.23-0.56; P < 0.001; number needed to treat [NNT] = 30) or in-hospital (RR: 0.32; 95% CI: 0.19-0.53; P < 0.001; NNT = 28), as well as EASY (Early Discharge After Transradial Stenting of Coronary Arteries) ≥II hematoma (RR: 0.51; 95% CI: 0.27-0.96; P = 0.04; NNT = 107). By contrast, DRA was associated with a higher risk of access site crossover (RR: 3.08; 95% CI: 1.88-5.06; P < 0.001; NNT = 12), a longer time for radial puncture (standardized mean difference [SMD]: 3.56; 95% CI: 0.96-6.16; P < 0.001), a longer time for sheath insertion (SMD: 0.37; 95% CI: 0.16-0.58; P < 0.001), and a higher number of puncture attempts (SMD: 0.59, 95% CI: 0.48-0.69; P < 0.001). CONCLUSIONS: Compared with conventional RA, DRA is associated with lower risks of RAO and EASY ≥II hematoma but requires longer time for radial artery cannulation and sheath insertion, more puncture attempts, and a higher access site crossover.

Simultaneous Dual Distal Radial Balloon Aortic Valvuloplasty for Larger Aortic Annuli.

Dual distal mini-balloon aortic valvuloplasty stabilized an 85-year-old patient with severe aortic stenosis. Puncturing both radial arteries solves the issue of large diameters at the aortic ring, introducing a feasible strategy in selected cases of fragile octogenarian patients with a high hemorrhagic risk. Moving at the anatomical snuffbox offers better postprocedural occlusion rates and better workspace ergonomics during the procedure.

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.

Switching From Proximal to Distal Radial Artery Access for Coronary Chronic Total Occlusion Recanalization.

Background: Distal radial access (DRA) was recently introduced in the hopes of improving patient comfort by allowing the hand to rest in a more ergonomic position throughout percutaneous coronary interventions (PCI), and potentially to further reduce the rate of complications (mainly radial artery occlusion, [RAO]). Its safety and feasibility in chronic total occlusion (CTO) PCI have not been thoroughly explored, although the role of DRA could be even more valuable in these procedures. Methods: From 2016 to 2021, all patients who underwent CTO PCI in 3 Hungarian centers were included, divided into 2 groups: one receiving proximal radial access (PRA) and another DRA. The primary endpoints were the procedural and clinical success and vascular access-related complications. The secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and procedural characteristics (volume of contrast, fluoroscopy time, radiation dose, procedure time, hospitalization time). Results: A total of 337 consecutive patients (mean age 64.6 ± 9.92 years, 72.4% male) were enrolled (PRA = 257, DRA = 80). When compared with DRA, the PRA group had a higher prevalence of smoking (53.8% vs. 25.7%, SMD = 0.643), family history of cardiovascular disease (35.0% vs. 15.2%, SMD = 0.553), and dyslipidemia (95.0% vs. 72.8%, SMD = 0.500). The complexity of the CTOs was slightly higher in the DRA group, with higher degrees of calcification and tortuosity (both SMD >0.250), more bifurcation lesions (45.0% vs. 13.2%, SMD = 0.938), more blunt entries (67.5% vs. 47.1%, SMD = 0.409). Contrast volumes (median 120 ml vs. 146 ml, p = 0.045) and dose area product (median 928 mGy×cm2 vs. 1,300 mGy×cm2, p < 0.001) were lower in the DRA group. Numerically, local vascular complications were more common in the PRA group, although these did not meet statistical significance (RAO: 2.72% vs. 1.25%, p = 0.450; large hematoma: 0.72% vs. 0%, p = 1.000). Hospitalization duration was similar (2.5 vs. 3.0 days, p = 0.4). The procedural and clinical success rates were comparable through DRA vs. PRA (p = 0.6), moreover, the 12-months rate of MACCE was similar across the 2 groups (9.09% vs. 18.2%, p = 0.35). Conclusion: Using DRA for complex CTO interventions is safe, feasible, lowers radiation dose and makes dual radial access more achievable. At the same time, there was no signal of increased risk of periprocedural or long-term adverse outcomes.

International Hand Function Study Following Distal Radial Access: The RATATOUILLE Study.

BACKGROUND: Distal radial access (DRA) has been proposed to improve procedure ergonomics and favor radial artery patency. Although promising data, nothing is known on evolving hand function after DRA. OBJECTIVES: This study sought to comprehensively evaluate hand function in patients undergoing DRA. METHODS: Real-world patients undergoing DRA undertook a thorough multimodality assessment of hand function implementing multidomain questionnaires (Disabilities of the Arm, Shoulder and Hand and Levine-Katz), and motor (pinch grip test) and sensory (Semmes-Weinstein monofilaments test) examinations of both hands. All assessments were performed at preprocedural baseline and planned at 1-, 6-, and 12-month follow-up (FU). Adverse clinical and procedural events were documented too. RESULTS: Data of 313 patients (220 men, age 66 ± 10 years) from 9 international centers were analyzed. The Disabilities of the Arm, Shoulder and Hand and the Levine-Katz scores slightly improved from baseline to FU (P = 0.008 and P = 0.029, respectively). Pinch strength mildly improved from baseline to FU (P < 0.001 for both the left and right hands). Similarly, touch pressure threshold appeared to faintly improve in both the left and right hands (P < 0.012 for all the sites). For both motor and sensory function tests, comparable findings were found for the DRA hand and the contralateral one, with no significant differences between them. Repeated assessment of all tests over all FU time points similarly showed lack of worsening hand function. Access-related adverse events included 19 harmless bleedings and 3 forearm radial artery and 3 distal radial artery occlusions. None affected hand function at FU. CONCLUSIONS: In a systematic multidimensional assessment, DRA was not associated with hand function impairment. Moreover, DRA emerges as a safe alternative vascular access.

Distal Versus Conventional Radial Access for Coronary Angiography and Intervention: The DISCO RADIAL Trial.

BACKGROUND: Currently, transradial access (TRA) is the recommended access for coronary procedures because of increased safety, with radial artery occlusion (RAO) being its most frequent complication, which will increasingly affect patients undergoing multiple procedures during their lifetimes. Recently, distal radial access (DRA) has emerged as a promising alternative access to minimize RAO risk. A large-scale, international, randomized trial comparing RAO with TRA and DRA is lacking. OBJECTIVES: The aim of this study was to assess the superiority of DRA compared with conventional TRA with respect to forearm RAO. METHODS: DISCO RADIAL (Distal vs Conventional Radial Access) was an international, multicenter, randomized controlled trial in which patients with indications for percutaneous coronary procedure using a 6-F Slender sheath were randomized to DRA or TRA with systematic implementation of best practices to reduce RAO. The primary endpoint was the incidence of forearm RAO assessed by vascular ultrasound at discharge. Secondary endpoints include crossover, hemostasis time, and access site-related complications. RESULTS: Overall, 657 patients underwent TRA, and 650 patients underwent DRA. Forearm RAO did not differ between groups (0.91% vs 0.31%; P = 0.29). Patent hemostasis was achieved in 94.4% of TRA patients. Crossover rates were higher with DRA (3.5% vs 7.4%; P = 0.002), and median hemostasis time was shorter (180 vs 153 minutes; P < 0.001). Radial artery spasm occurred more with DRA (2.7% vs 5.4%; P = 0.015). Overall bleeding events and vascular complications did not differ between groups. CONCLUSIONS: With the implementation of a rigorous hemostasis protocol, DRA and TRA have equally low RAO rates. DRA is associated with a higher crossover rate but a shorter hemostasis time.