How to Omit the Potential Pitfalls in Distal Radial Access: Lessons From Cadaveric and CTA Analysis.

OBJECTIVES: To verify the anatomical basis, ideal puncture sites, and potential pitfalls of the distal radial artery (dRA) in the anatomical snuffbox region for distal radial access (dTRA). MATERIALS AND METHODS: Overall, 26 formalin-fixed upper limbs and computed tomography angiography (CTA) of the upper limbs of 168 consecutive patients were studied. Cadaveric dissection and dRA 3D reconstruction were used to evaluate the dRA route for dTRA. The puncture sites, dRA diameter, and angle of the dRA and tendons of the extensor pollicis brevis were also measured in the patients and cadavers. RESULTS: The cadaver dissection provided more insights than did the dRA 3D reconstruction. However, preoperative evaluation had better diagnostic accuracy (p=0.024). Puncture sites 1 and 3 had a high success rate (63.2% possible success rate, 191/302). The DISFAVOR theory was put forward, in which 8 types of potential pitfalls that may interrupt puncture procedure or lead to a surgical failure were observed, including occlusion, stenosis, tortuosity, arteriovenous fistula, angioma, different radial artery (RA) ramifications, radial veins, and cephalic veins. The mean diameter of dRA based on cadaver dissection and CTA was 2.53 (SD=0.73) and 2.63 (SD=0.69) mm, respectively. Furthermore, the minimum distance from the outer layer of dRA to the skin was 5.71 (SD=2.0) mm based on CTA. The angle between the dRA and tendons of extensor pollicis brevis (TEPB) based on cadaver dissection and CTA was 58.0° (SD=21.5°) and 51.8° (SD=16.6°), respectively. CONCLUSIONS: Puncture sites 1 and 3 were more suitable for the dTRA, and we put forward the DISFAVOR theory to summarize the 8 types of potential pitfalls during the use of dTRA.

Long-term outcomes of arteriovenous snuffbox fistulas for hemodialysis.

OBJECTIVE: Autologous arteriovenous fistulas in the arm have been shown to be superior to all other types of arteriovenous access and should be placed as far distally as possible. The aim of the present study was to delineate the advantages of snuffbox fistulas (SBFs). METHODS: From January 2007 through April 2017, first time or new arteriovenous fistula surgery was performed in 375 patients. If feasible, an SBF was chosen. The observation period ended in December 2019. The focus of the present study was on the patency rates, redo surgery, complications, and mortality rates. RESULTS: SBFs were created in 236 patients (92 women and 144 men; mean age, 67 years; 46% with diabetes). Within the first 6 weeks, 11% of the fistulas had failed. The primary patency rates were 75%, 69%, 64%, 61%, 60%, and 58% after 1, 2, 3, 5, 7, and 9 years, respectively. The secondary patency rates were 86%, 83%, 80%, and 77% after 1, 2, 3, and 5 years, respectively. Age, sex, and the presence of diabetes mellitus had no effect on the primary patency rates. Patients with a right-sided SBF had significantly worse primary patency. Of the 236 patients, 154 (65%) had died during the observation period. The incidence of surgical site infection within the first 30 days and access-related ischemia during the observation period was <1%. CONCLUSIONS: The results from the present study have shown that with suitable anatomic conditions, a SBF is a good choice for the creation of dialysis access. The patency rates were encouraging, and it offers the longest puncturable segment of the cephalic vein. Also, the rate of perioperative complications was low.

Safety and efficacy of coronary angiography and percutaneous coronary intervention via distal transradial artery access in the anatomical snuffbox: a single-centre prospective cohort study using a propensity score method.

BACKGROUND: This study investigated the safety and efficacy of coronary angiography (CAG) and percutaneous coronary intervention (PCI) via distal transradial artery access (d-TRA). METHODS: For this single-centre prospective cohort study, a total of 1066 patients who underwent CAG or PCI procedures from September 2019 to November 2020 were included. Patients were divided into two groups: the d-TRA group (346) and the conventional transradial artery access (c-TRA) group (720) based on access site. A total of 342 pairs of patients were successfully matched using propensity score matching (PSM) for subsequent analysis. RESULTS: No significant differences in puncture success rate, procedural method, procedural time, sheath size, contrast dosage or fluoroscopy time were noted between the two groups. The puncture time in the d-TRA group was longer than that in the c-TRA group (P < 0.01), and the procedure success rate was lower than that in the c-TRA group (90.94% vs. 96.49%, P = 0.01). The haemostasis time in the d-TRA group was shorter than that in the c-TRA group (P < 0.01), and the visual analogue scale (VAS) was lower than that in the c-TRA group (P < 0.01). In addition, the prevalence of bleeding and haematoma in the d-TRA group was lower than that in the c-TRA group (1.75% vs. 7.31%, P < 0.01; 0.58% vs. 3.22%, P = 0.01, respectively). No significant difference in the incidence of numbness was noted between the two groups. No other complications were found in two groups. CONCLUSION: d-TRA is as safe and effective as c-TRA for CAG and PCI. It has the advantages of improved comfort and fewer complications. Trail registration Chinese Clinical Trial Registry, ChiCTR1900026519.

Comparison of the Safety, Efficacy, and Procedural Characteristics Associated with Proximal and Distal Radial Access for Diagnostic Cerebral Angiography.

OBJECTIVES: Radial access is an increasingly popular approach for performing cerebral angiography. There are two sites for radial artery puncture: proximal transradial access (pTRA) in the wrist and distal transradial access (dTRA) in the snuffbox. These approaches have not been directly compared. MATERIALS AND METHODS: Consecutive diagnostic cerebral angiograms performed at a single institution were retrospectively reviewed. Outcomes included fluoroscopy time, radiation dose, contrast volume, time to obtain access, procedure duration, and time to discharge home. Success rates as well as minor and major complication rates associated with each approach were also compared. Multivariate linear regression models were used to determine the relationship between access site and outcomes while adjusting for covariates. RESULTS: A total of 287 angiograms on 244 patients met the inclusion criteria. pTRA was associated with shorter fluoroscopy time (ß -2.54, 95% CI -4.18 - -0.9, p = 0.003) and lower radiation dose (ß -242.89, 95% CI -351.55 - -134.24, p < 0.001), but not contrast volume. Time to obtain access, procedure duration, and time to discharge home were similar between approaches. A total of 10 minor complications occurred with similar rates for each approach (8 for dTRA, 2 for pTRA, p = 0.168) and there were no major complications. The conversion rate to femoral access was low (1.05% overall) and did not differ with approach. CONCLUSION: dTRA and pTRA are associated with similarly high rates of safety and efficacy. Procedure duration, time to obtain access, and time to discharge did not differ between approaches.

Feasibility of Distal Radial Access for Coronary Angiography and Percutaneous Coronary Intervention: A Single Center Experience.

OBJECTIVE: Asymptomatic radial artery occlusion remains the most common complication in transradial coronary interventional procedure. To prevent radial artery occlusion, distal transradial access (dTRA) has been suggested recently. In this article, we aim to describe our experience and to assess feasibility and safety of this new access site for routine coronary angiography (CAG) and percutaneous coronary intervention (PCI). METHODS: We retrospective analyzed 1,063 consecutive patients who were assigned to undergo CAG or procedural PCI through dTRA between 1 January 2018 and 31 December 2019 at Affiliated Zhongshan Hospital of Dalian University. The size of radial sheath used was 5 or 6 French. The sheath was removed at procedure termination, and hemostasis was obtained by compression bandage with gauze. The success rate of dTRA access defined by successful radial artery cannulation on the first dTRA side attempted, the cause of access failure, the hemostasis duration, the incidence of post-catheterization radial artery occlusion, and the other access-related complications including hematoma of forearm and thumb numbness were assessed. RESULTS: Radial artery cannulation via dTRA was successful in 953 of 1,063 patients with a success rate of 89.7%. Mean age of successful cases was 64.6 ± 11.2 years (26-94 years) with 339 (35.6%) women. A total of 363 (38.1%) cases were PCI. Among them, 95 cases (10%) underwent urgent PCI, including primary PCI in 64 patients with ST-segment elevation myocardial infarction and immediate PCI (<2 h from hospital admission) in 31 patients with very high-risk non-ST-segment elevation acute coronary syndrome. A total of 269 (28.2%) cases were via left dTRA. The 6 French sheath was used in 602 (63.2%) cases. Hemostasis was obtained within 2 h in 853 (89.5%) patients. There were 110 (10.3%) procedural failures: 59 (5.6%) cases of artery puncture failure, 49 (4.9%) cases of guide wire insertion failure, and 2 (0.2%) cases of sheath insertion failure. Complications potentially related to distal radial access included radial artery occlusion at the access site (13 cases, 1.4%), forearm radial artery occlusion (4 cases, 0.4%), hematoma of forearm (5 cases, 0.5%), and transient thumb numbness (2 cases, 0.2%). CONCLUSION: dTRA is a feasible and safe access and can be used as a rational alternative to traditional radial access for routine coronary interventional procedure.

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

BACKGROUND: Radial artery occlusion is a common complication after coronary angiography and percutaneous coronary intervention via the transradial access. In recent years, coronary angiography and percutaneous coronary intervention via the distal transradial access has gradually emerged, but recanalization of the occluded radial artery through the distal transradial access has rarely been reported. CASE PRESENTATION: A 67-year-old female with arterial hypertension and diabetes mellitus was admitted to the hospital due to chest pain for three hours. She was diagnosed with acute myocardial infarction. After admission, the patient successfully underwent emergency coronary angiography and percutaneous coronary intervention through the right transradial access. Radial artery occlusion was found after the operation, and recanalization was successfully performed through the right distal transradial access before discharge. Immediately after the operation and one month later, vascular ultrasonography showed that the antegrade flow was normal. CONCLUSIONS: This report presents a case of radial artery occlusion after emergency coronary angiography and percutaneous coronary intervention in which recanalization was successfully performed through the right distal transradial access. This case demonstrates that recanalization of a radial artery occlusion via the distal transradial access is safe and feasible.

Snuffbox arteriovenous fistulas have similar outcomes and patency as wrist arteriovenous fistulas.

OBJECTIVE: Radial artery-based wrist arteriovenous fistulas (AVFs) are commonly created as an initial upper extremity arteriovenous access. A more distal access site, such as the anatomic snuffbox AVF, can also be created. Although much has been written about wrist AVFs, outcomes of snuffbox AVFs are unclear. Our goal was to compare perioperative and midterm outcomes between these two types of distal access. METHODS: The Vascular Quality Initiative database was queried for all patients undergoing snuffbox AVFs and wrist AVFs from 2011 to 2017. Unmatched and matched analyses were performed for baseline characteristics and outcomes at 6 months for ischemic steal, wound infection, and arm swelling. Multivariable analysis was performed for unmatched and matched analyses for primary patency, surgical or endovascular repair, and patient survival. Kaplan-Meier matched analysis was performed for primary patency, freedom from surgical or endovascular intervention, and survival. RESULTS: We identified 4525 distal forearm fistulas: 179 (4%) snuffbox AVFs and 4346 (96%) wrist AVFs. The average age was 59 ± 14.7 years, and 72.3% of patients were male. There were no significant differences in baseline demographics or comorbidities of patients with snuffbox AVFs and wrist AVFs except that patients with snuffbox AVFs had fewer tunneled lines at access creation (70.2% vs 65.2%; P = .046) and had a lower American Society of Anesthesiologists class. There were no significant differences in unmatched outcomes at 6 months for ischemic steal (0.8% vs 1.9%; P = .336), wound infection (0% vs 0.2%; P = .649), and arm swelling (0.8% vs 1.3%; P = .592). Matched analysis showed no significant differences in baseline characteristics and outcomes at 6 months for ischemic steal (0% vs 1.8%; P = .146), wound infection (0% vs 0%), and arm swelling (0.9% vs 1.2%; P = .789). Kaplan-Meier matched analysis showed no significant differences between snuffbox AVFs and wrist AVFs at 6 months for primary patency (51% vs 48%; P = .61), freedom from endovascular intervention (84.5% vs 82.5%; P = .98), freedom from surgical intervention (90% vs 86%; P = .08), and survival (92% vs 96%; P = .1). In multivariable analysis of unmatched data, snuffbox AVFs and wrist AVFs had similar primary patency (hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.75-1.26; P = .83), likelihood of surgical intervention (HR, 0.61; 95% CI, 0.35-1.05; P = .074) and endovascular intervention (HR, 0.96; 95% CI, 0.65-1.42; P = .83), and survival (HR, 1.47; 95% CI, 0.9-2.4; P = .128). CONCLUSIONS: Snuffbox AVFs have midterm results similar to those of wrist AVFs.

Slender distal radial five French coronary shockwave lithotripsy.

Despite technological evolution, percutaneous coronary interventions targeting coronary calcifications remain challenging and associated with high rates of complications and adverse outcomes. Over the years, rotational atherectomy has emerged as the reference treatment of calcified coronary artery lesions despite some inherent limitations. Also, rotational atherectomy typically requires relatively large guiding catheters which may unfavorably impact on the decision for transradial access, especially when radial artery is small, and consequently offset the relevant clinical benefits associated to transradial access. Recently, a new technology has been introduced in interventional practice to implement coronary lithotripsy. The device implements multiple small emitters enclosed in a coronary balloon creating sonic pressure waves to selectively fracture calcium within the plaque and favorably modify vessel compliance. Owing to its specific design, coronary shockwave lithotripsy could be used with small bore guiding catheters which may allow for straightforward transradial percutaneous treatment of calcified coronary lesions even in patients with a small radial artery. To illustrate this concept, we report the first experience of slender transradial coronary shockwave lithotripsy with a five French sheathless guiding catheter.

Distal transradial artery access in the anatomical snuffbox for coronary angiography as an alternative access site for faster hemostasis.

OBJECTIVES: This study investigated the feasibility, safety, and the potential benefit of faster hemostasis with the distal transradial artery access (TRA). BACKGROUND: TRA has been shown to be associated with lower bleeding and vascular complications. Limited data are available regarding the new technique of accessing the distal radial artery in the anatomical snuffbox. METHODS: We retrospectively reviewed 202 consecutive patients who underwent coronary angiography and intervention with distal TRA. Two hundred and six conventional TRA cases were collected as a comparison arm. RESULTS: Out of 408 patients, successful distal radial access was obtained in 99.5% (201/202) in the distal TRA cases and 99.0% (204/206) in the conventional TRA cases. The rate of access site crossover was 2.0% (4/202) for distal TRA. Right distal radial artery was accessed in 176 cases (87.6%). Mean access time from local anesthesia to radial flush was 7.3 min. Ninety cases (44.8%) were percutaneous coronary interventions (PCIs) and the mean heparin dose used was 4,448 units (6,009 units for PCI and 3,182 units for diagnostic catheterization). Mean time to remove TR band was 104.7 min (120.8 min for PCI and 91.7 min for diagnostics). Follow-up ultrasound study showed two partial occlusions (1.0%) and one arteriovenous fistula (0.5%) that resolved with prolonged TR band inflation. CONCLUSIONS: Despite longer time to access the distal radial artery in the anatomical snuffbox, it is a safe and feasible alternative to conventional TRA and might result in shorter time to hemostasis especially in cases of PCI.

Importance of measurement of the diameter of the distal radial artery in a distal radial approach from the anatomical snuffbox before coronary catheterization.

Coronary catheterization by a distal radial approach at the site of the anatomical snuffbox has recently been reported to be both safe and useful. No data are available on the diameter of the distal radial artery (DRA) in Japan, and it is unclear whether the DRA is large enough to withstand the insertion of a conventional sheath by a traditional radial approach. We enrolled 142 patients who underwent coronary catheterization and evaluated the vessel diameter of the DRA using ultrasound. The vessel diameter of the DRA in the anatomical snuffbox (2.6 ± 0.5 mm) was significantly smaller than that of the proximal radial artery (PRA) at the conventional puncture site (3.1 ± 0.4 mm). The difference in vessel diameter between the DRA and PRA was 0.5 ± 0.4 mm, and the DRA/PRA ratio was 0.8 ± 0.1. Although the vessel diameter of the DRA was positively correlated with that of the PRA (r = 0.66, p < 0.0001), in some cases the DRA was extremely small compared to the PRA. When the vessel diameter of the DRA is smaller than the outer diameter of the sheath scheduled for use, we should puncture the PRA at the outset. We could perform coronary catheterization by a distal radial approach without major bleeding or adverse events, and there was no radial artery occlusion at the site of the anatomical snuffbox or the forearm. For coronary catheterization by a distal radial approach, we should evaluate whether there is sufficient vessel diameter using ultrasound before the procedure. In addition, this approach can be an effective option from the viewpoint of radial artery preservation.

Analysis of the diameter of the distal radial artery at anatomic snuffbox by ultrasonography in patients scheduled for coronary intervention.

BACKGROUND: Assessing the size of the distal radial artery (DRA) in anatomic snuffbox (AS) before coronary intervention is extremely important in the selection of suitable patients, improving the success rate of puncture and reducing the complications. OBJECTIVE: To evaluate the diameter of the DRA in AS and its influencing factors in Chinese patients scheduled for coronary intervention. METHODS: Ultrasound was used to detect the inner diameter of vessels. A total of 1182 patients were involved in the study. RESULTS: In all patients, the mean inner diameters of the DRA, conventional radial artery (CRA) and ulnar artery (UA) were 2.00 ± 0.43 mm, 2.38 ± 0.51 mm and 1.99 ± 0.47 mm, respectively. The proportion of DRA diameter ⩾2.0 mm was 53% (in all patients), 64% (in males), 36% (in females), respectively. The DRA/CRA ratios were 0.85 ± 0.13 in all patients, 0.86 ± 0.13 in males and 0.84 ± 0.13 in females. The diameter of the DRA was strongly positively correlated with the diameter of the CRA (r = 0.750, p < 0.05), and weakly correlated with the body mass index (r = 0.303, p < 0.05) and the diameter of the UA (r = 0.304, p < 0.05). Multivariate regression analysis showed that female sex, age ⩾60 years, body mass index <24 kg/m2, previous CRA/DRA access and history of coronary artery disease were independent predictors of the DRA diameter <2.0 mm. CONCLUSION: Measurement of the diameter of the DRA by ultrasonography may offer important information prior to coronary catheterization.

Snuffbox distal transradial access (dTRA) for arteriovenous fistuloplasty in Singapore: Going distal is safe.

AIM: Arteriovenous fistula (AVF) dysfunction resulting from stenosis or occlusion, is a prevalent issue in end-stage renal failure patients reliant on autogenous AVFs for dialysis. Recently, a distal transradial approach (dTRA) has emerged, offering advantages such as diminished access site complications, better patient comfort and reduced risk of radial artery occlusion. Our study seeks to assess the effectiveness, outcomes and complication rates of employing dTRA for arteriovenous fistuloplasty in Singaporean patients. METHODS: A retrospective review of all dTRA fistuloplasties performed on dysfunctional or slow to mature AVFs from 2017 to 2023 in our institution was performed. Patients with a distal radial artery measuring 2 mm or more with no evidence of occlusion or thrombosis were included. Patients who required central venoplasty or cutting balloon angioplasty were excluded. Outcome measures included technical success, mean procedure duration, complications and post-intervention primary patency at 1, 3 and 6 months. Patients were followed up for 12 months post-intervention. RESULTS: A total of 37 patients were included. 97.3% of patients undergoing dTRA fistuloplasty had radiocephalic fistulas while 2.7% had brachiobasilic fistulas. There was 100% technical success (defined as success in radial artery cannulation, sheath insertion and crossing of stenotic lesions) in our study as all patients successfully underwent fistuloplasty via dTRA approach. One-month patency rate was 97.4%, 3-month patency rate was 92.1% and 6-month patency rate was 86.8%. There were no immediate complications (haematoma, infection, bleeding, pseudoaneurysm, occlusion) of the radial artery post-intervention. CONCLUSION: Our paper illustrates the safety and efficacy of utilising dTRA for arteriovenous fistuloplasty. This approach offers distinct benefits in addressing non-mature or dysfunctional distal forearm arteriovenous fistulas and should be taken into account in anatomically suitable cases.

Transverse snuffbox perforator flap for a first-web contracture: an anatomical study and case report.

This cadaveric study describes a dorsal wrist transverse elliptical cutaneous flap, based on radial artery cutaneous perforators in the region of the snuffbox. The flap was then successfully used in a child with thumb hypoplasia and severe first-web contracture.

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 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.

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.

Snuffbox Versus Wrist Radiocephalic Arteriovenous Fistulas: 10 Years Experience.

Background The wrist radiocephalic arteriovenous fistula (RCAVF) is the initial suggested procedure for establishing hemodialysis vascular access (HVA) in the most distal site of the upper limb. The anatomical snuffbox arteriovenous fistula (SBAVF) is barely utilised, despite its remote location. In this study, we aimed to analyse and compare the results of SBAVF and RCAVF in terms of their maturity, patency, and failure rates. Methodology This descriptive, retrospective study compared outcomes between SBAVF and RCAVF in terms of maturation, patency, and failure. All patients with chronic kidney disease who attended and underwent either procedure at Betsi Cadwaladr University Health Board between 2013 and 2023 were studied. Results In a period of 10 years, 179 patients were included. Overall, 102 (57%) were male and 77 (43%) were female, with a male-to-female ratio of 1.3:1. Wrist radiocephalic fistula was the dominant type of surgery done in 76% (n = 136), while the snuffbox radiocephalic fistula was done in fewer than 24% (n = 43) of patients. Most patients underwent a successful arteriovenous (AV) fistula (n = 105, 58.7%), in contrast to 67 patients whose fistulas failed. There was a significant relationship between fistula failure and complications (p = 0.000). There was no significant effect of the fistula site, hypertension, diabetes, cardiac diseases, smoking, peripheral vascular disease, or central vein stenosis on the failure of the AV fistula (p = 0.127, 0.534, 0.510, 0.397, 0.017, 0.68, and 0.371, respectively). Conclusions The snuffbox AV fistula is a suitable and feasible first choice for patients on hemodynamic therapy.

Distal Transradial Access in the Anatomical Snuffbox for Interventional Coronary Procedures: Analysis of Access Site Pain and Complications.

INTRODUCTION: A novel arterial access distally on the radial artery through the anatomical snuffbox has been recently described for coronary interventional procedures. However, there is insufficient data comparing the advantages and limitations of distal transradial access (dTRA), conventional transradial access (TRA), and transfemoral access (TFA). The aim of this study was to compare the three access sites regarding local pain and complications during or after coronary interventional procedures. METHODS: This prospective observational single-center study included 211 patients undergoing cardiac catheterization or percutaneous coronary intervention, divided into three groups: dTRA (n=69), TRA (n=71), and TFA (n=71). The access site was chosen at the discretion of three operators. We administered a questionnaire to all patients, addressing local pain or discomfort during or after the procedure and the occurrence of possible complications such as distal pallor, local bleeding, and purple color on the access site. RESULTS: Pain on the access site during the procedure was reported more frequently in the TRA group (dTRA 15.9% vs. TRA 32.4% vs. TFA 15.5%). There were no differences in the occurrence of local pain after the procedure in all three groups (29.6% in the dTRA group, 28.2% in the TRA group, and 26.8% in the TFA group). Pain intensity, when it occurred, was higher in the dTRA group (dTRA 5.8 vs. TRA 4.8 vs. TFA 4.6 on a 1-10 scale), as was its duration (dTRA 13.7 vs. TRA 7.6 vs. TFA 8.2 days). Only two local bleeding events were reported, both in the TFA group. No major complications were recorded. CONCLUSION: The occurrence of local pain on the puncture site after coronary interventional procedures did not differ among the three groups. The dTRA group presented a lower incidence of pain during the procedure when compared to TRA and a lower incidence of purple color when compared to TFA. However, pain intensity and duration were higher in the dTRA group when pain was reported. Using dTRA for coronary procedures is a feasible and safe strategy in selected cases.