Commentary: Distal Transradial Access: From Novelty to Standard of Care?

As the incidence of coronary heart disease increases annually, coronary angiography and percutaneous coronary intervention procedures are also increasing. The femoral artery and radial artery paths are commonly used for percutaneous coronary intervention, but their clinical application is limited to a certain extent due to many postoperative complications. The distal transradial access path is a new surgical path for coronary angiography and percutaneous coronary intervention. In this study, we reviewed the most relevant and recent articles related to distal transradial access and found that coronary angiography or interventional therapy using the distal transradial access path is safe and effective in patients with acute coronary syndrome and complex coronary artery disease. The distal transradial access path is expected to be the first choice for coronary angiography or percutaneous coronary intervention in patients with acute coronary syndrome and complex coronary artery disease.

Background Transradial access (TRA) is the recommended approach for coronary procedures considering safety benefits over femoral access with radial artery occlusion (RAO) being the most frequent complication. Although usually not clinically significant, the presence of RAO affects potential future procedures and medical treatments. Distal TRA (dTRA) has been suggested to reduce the risk of postprocedural RAO compared to conventional TRA (cTRA) with, however, inconsistent results in clinical trials. Purpose This study aimed to compare the efficacy and safety of dTRA versus cTRA in patients undergoing diagnostic coronary angiography. Methods The RAPID trial is a single-center, open-label, 2x2 factorial, randomized study of patients undergoing coronary angiography through a 6-F radial access. The trial was stopped early by the data and safety monitoring board after the second pre-planned interim analysis and inclusion of 600 participants. Patients were randomized to dTRA or cTRA with further stratification according to periprocedural heparin use and preexisting oral anticoagulation. The primary endpoints were the incidence of RAO assessed by vascular ultrasound and puncture-site related bleedings. Results The final study population consisted of 298 patients randomized to dTRA and 302 patients to cTRA. Periprocedural heparin was administered in 382 patients (63.7%) and percutaneous coronary intervention was performed in 161 cases (26.8%) without differences between the study groups (p=0.700 and p=0.465; respectively). Distal TRA was associated with a significantly increased number of puncture attempts (2.4 ± 2.0 versus 1.5 ± 1.2; p<0.001) and failed punctures leading to access site crossover (11.7% versus 5.0%; p=0.003). Consequently, the total procedure time was longer in the dTRA group (30 min versus 25 min; p=0.004) without increasing fluoroscopy time (p=0.320), dose area product (p=0.245), or contrast volume (p=0.884). Patent hemostasis was achieved in 91.7% of patients with cTRA. The rates of RAO (16.1% versus 15.6%, p=0.855) and puncture-site related bleedings (6.7% versus 8.3%; p=0.466) were similar in both groups. Conclusions According to this study, dTRA does not reduce the risk of RAO or bleeding events compared to cTRA.

BackgroundTransradial access is a well-known alternative to conventional transfemoral access for interventional procedures. Recently, transradial access through the “snuffbox”, which lies in the radial dorsal aspect of the hand, has been introduced as a new technique with positional versatility. In this study, we aimed to evaluate the clinical feasibility and safety of distal transradial access for interventional procedures in a retrospective, multicenter study.Material & methodsDistal transradial access was attempted in 46 patients (36 men and 10 women; mean age, 64 years) who underwent 47 consecutive procedures from January 2018 to December 2019. Procedures included chemoembolization (19/47, 40.4%), bronchial artery embolization (7/47, 14.9%), renal intervention (3/47, 6.4%), arteriovenous fistula angioplasty (7/47, 14.9%), subclavian artery stenting (5/47, 10.6%), other embolization (5/47, 10.6%), and uterine artery embolization (1/47, 2.1%). We recorded the success rate of the procedures, complications, and postprocedural hemostasis time during the follow-up period.ResultsThe technical success of distal transradial access without major complications was 97.9% (46/47). Of the 46 patients, one patient (2.2%) had a minor complication, which was a thrombotic segmental occlusion of the distal radial artery. Of the enrolled patients, only one patient did not complete the transradial access procedure via the snuffbox because the left proximal subclavian artery was occluded and a crossover to conventional transfemoral access was performed. The mean postprocedural hemostasis time was 131.7 minutes (range, 120–360 minutes).ConclusionDistal transradial access can be a valid option for the endovascular treatment of various noncoronary interventions with technical feasibility and safety.

BackgroundThe routine radial artery (RA) puncture may fail when anatomical variation of the RA is encountered. Superficial radial artery (SRA) is one of the anatomic variants of the RA, with the incidence of about 1 to 1.5%. Recently, distal transradial access (dTRA) has emerged as a novel approach for coronary catheterization (CC), but performing CC through dTRA in patient with SRA has never been reported.Case presentationA 57-year-old male was admitted to hospital due to intermittent chest pain for 4 days. He was diagnosed with unstable angina pectoris and planned to receive coronary angiography (CAG). Before the operation, the existence and course of SRA were confirmed by palpation and ultrasonography with color Doppler. We marked the puncture site under the guidance of ultrasonography and successfully performed CC through the dTRA during patient’s hospitalization.ConclusionsAs far as we know, this is the first report that presents a case of SRA and percutaneous coronary intervention (PCI) treatment in which was successfully performed through dTRA. It is safe and feasible to perform CC via dTRA in case of SRA, and dTRA seems to be the preferred access.

Distal transradial access (dTRA) has received extensive attention and has gradually become an alternative access for cardiac interventions. However, with the widespread use of dTRA, access complications such as distal radial artery occlusion (dRAO), haematoma, pseudoaneurysm and arteriovenous fistula (AVF) have been reported. In this study, we report a case of AVF after dTRA and review the related literature. A 54-year-old female, who underwent percutaneous coronary intervention (PCI) 2 years ago, was admitted to the hospital with discomfort in her thumb. On admission, a mass was found at the puncture site, and ultrasound revealed a fistula between the distal radial artery (DRA) and the cephalic vein (CV). The patient was treated with manual compression for 2 h. Three months later, the mass was smaller than before, the symptoms had resolved and the fistula was found to have closed on repeat ultrasound. Understanding the mechanisms underlying the occurrence of AVF and the principles guiding the treatment of the potential risks associated with AVF after dTRA is important and allows for the effective prevention of AVF and accurate prognostic prediction.

This study investigated the feasibility, safety, and the potential benefit of faster hemostasis with the distal transradial artery access (TRA). 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. 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. 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. 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.

This study aims to evaluate the feasibility, efficacy, and safety of distal transradial access (dRA) for the endovascular management of malfunctioning dialysis fistulas. This study also compares dRA with conventional access techniques, such as proximal radial and transvenous access, focusing on technical success, clinical outcomes, and vascular access site complications (VASCs). A retrospective multicenter study was conducted across four hospitals, including 292 patients treated between January 2019 and June 2024. Of these, 57 patients underwent dRA, and 235 received proximal radial or transvenous access. Key outcomes included technical success (successful completion of the procedure), clinical success (restoration of functional dialysis access), and complication rates. Data were collected on procedure times and complication profiles. Technical success was achieved in 96.5% of patients undergoing dRA, compared to 98.3% in those receiving conventional access (p = 0.388). Clinical success was similar between groups (96.5% vs. 97%, p = 0.835). The overall complication rate was 10.5% for dRA and 8.5% for conventional access (p = 0.632). Cannulation time was longer for dRA (109.1 vs. 91.9 s, p < 0.001), but total procedure duration was comparable between the groups. No major complications were observed in either cohort, and improved post-procedure access flow rates were recorded in all patients. Distal transradial access is a feasible and effective approach for the endovascular management of malfunctioning dialysis fistulas, with outcomes comparable to conventional access techniques. It provides a safe alternative, particularly for patients with complex fistulas, while maintaining a low complication profile.

BackgroundConventionally, subclavian stenting has been performed via the femoral artery, but this approach is associated with complications such as bleeding, patient discomfort, and prolonged recovery. The transradial artery access (TRA) has gained popularity due to its lower vascular complication rates, though it carries a risk of radial artery occlusion (RAO). The distal transradial access (dTRA) has emerged as an alternative with lower occlusion rates.ObjectiveThis study aimed to assess the safety and technical feasibility of bilateral distal transradial access for percutaneous interventions in subclavian artery stenosis.MethodsWe present 10 cases of subclavian artery stenosis, in whom diagnostic angiography was performed by SIM2 catheter via the contralateral side access. Ipsilateral side distal radial artery was subsequently accessed for balloon-expandable stents delivery.ResultsAmong the 10 patients, 9 were male and 1 was female, with a mean age of 65.8 years. The systolic pressure difference between the left and right arms was 21.00 mmHg. Among them, 2 cases had 80% stenosis, 2 cases had total occlusive lesions, and 6 cases had 90% stenosis. 1 case had right subclavian artery stenosis, while 9 cases had left subclavian artery stenosis. The results showed a 100% success rate for bilateral distal radial artery puncture and a 100% completion rate for subclavian stenosis intervention procedures. No RAO or subclavian artery restenosis was observed during the 1-month follow-up.ConclusionIn patients with subclavian stenosis bilateral dTRA is a safe and minimally invasive method for patients and ergonomically comfortable for operators.

Distal trans-radial access (dTRA) is a novel technique of arterial cannulation in coronary interventions. The comparative efficacy of dTRA and conventional trans-radial access (TRA) in attenuating peri-procedural complications is unknown. Embase and PubMed/MEDLINE were searched from their inception until June 25, 2022, for randomized clinical trials. Outcomes included were radial artery occlusion (RAO), radial artery spasm, hemostasis time, access time, unsuccessful cannulation, crossover rate, and early discharge after trans-radial stenting of coronary arteries (EASY) type I-III hematomas. Statistical analysis was conducted using the random effects model to derive risk ratios (RRs) and mean differences (MDs) with their corresponding 95% confidence intervals (CIs). A total of 6 randomized clinical trials comprising 3240 patients were included. Subjects were predominantly male (73%) and had a mean age of 66 years. The dTRA group had a lower risk of RAO [RR 0.43 (95% CI, 0.26-0.69); P = 0.0005; I 2 = 0%] and had a shorter hemostasis time [MD -22.85 min (95% CI, -39.06 to -6.65); P = 0.006; I 2 = 99%]. The dTRA group had a higher crossover rate [RR 3.04 (95% CI, 1.88-4.91); P = 0.00001; I 2 = 56%] and a longer access time [MD 0.68 min (95% CI, 0.17-1.18); P = 0.009; I 2 = 99%]. The TRA group had a lower rate of unsuccessful cannulation [RR 0.81 (95% CI, 0.70-0.95); P = 0.01; I 2 = 92%]. There was no significant difference between the groups for radial artery spasm and EASY type I-III hematomas. dTRA is a safe alternative to conventional TRA for coronary interventions with a lower risk of RAO. Future trials are required to further compare both approaches.

Background: Radial artery occlusion (RAO) is one of the most common consequences of transradial artery access (TRA) in invasive cardiovascular procedures; therefore, alternative approaches, such as distal radial artery access (DRA), emerged. This study compares proximal and distal radial access for long-term RAO. Objectives: This study compares long-term RAO incidence with proximal and distal radial access following invasive cardiovascular procedures. Material and Methods: This is a retrospective cohort study. The subjects comprised patients with heart disease who underwent invasive cardiovascular procedures using radial access at Dr. Hasan Sadikin General Hospital Bandung between July 2017 and December 2020. The patients were categorized into two groups based on their access type: proximal and distal. The incidence of long-term RAO was evaluated through Doppler ultrasound at least one-year post-TRA. Results: The study included 107 patients (proximal = 72 patients; distal = 35 patients). The mean age was 58.2 ± 8.26 years, with a predominance of male patients (79.4%) and smokers (65.4%). The majority of procedures were interventional (58.2%). Baseline characteristics were comparable between the two groups, except for selecting the access side, which was more prevalent on the left side in the distal group. Long-term RAO occurred in 8 patients (7.48%), with 7 cases (9.72%) in the proximal group and 1 case (2.86%) in the distal group (p=0.269). Conclusion: The study findings reveal no significant difference in the incidence of long-term RAO between proximal and distal radial access in invasive cardiovascular procedures Keyword: Distal Radial Access, Intensive Cardiovascular Procedure, Longterm, Proximal Radial Access, Radial Artery Occlusion

Distal versus proximal transradial access for diagnostic cerebral angiography: A single-center experience.

This study compared the efficacy and safety of distal transradial access (dTRA) and common femoral artery access (CFA) for endovascular treatment of non-coronary arterial disease. 102 interventions were divided into dTRA (n = 51) and CFA (n = 51) groups; the puncture success rate was 100% in both groups. The mean number of punctures and puncture time were greater in the dTRA than CFA group (1.86 vs 1.04 and 3.96 vs ≤1.00min, p < .001 for both), whereas the access-related complication rate was comparable. The surgical success rate was higher in the CFA than dTRA group (98.0 vs 84.3, p = .036), and the operative time was longer in the dTRA than CFA group (99.09 vs 84.10min, p = .017). The postoperative adverse event rate was not different between the dTRA and CFA groups. dTRA is a safe and feasible access for non-coronary arterial disease and is comparable to CFA in terms of puncture success, access-related complications, and major adverse events. The dTRA is inferior to CFA in the treatment of lower extremity arterial disease. Due to the increase in the operation time and the contrast medium volume in the dTRA, it is necessary to be vigilant about contrast nephropathy and late radiological random side effects.

ABSTRACTBackgroundPercutaneous coronary intervention (PCI) is an important treatment for coronary artery disease (CAD). Distal transradial access (dTRA) has gained popularity as an alternative to conventional transradial access (TRA) in cardiovascular interventional procedures. However, some patients may experience hand dysfunction after undergoing TRA or dTRA procedures.MethodsIn this study, the literature from the PubMed and Web of Science (WOS) databases was reviewed and 11 randomized controlled trials (RCTs) were selected. Meta‐analysis and narrative synthesis were used to evaluate the hand dysfunction and vascular complications.ResultA total of 6903 participants were included in the study. The average age was 62.8 years, and 66.9% were male. In terms of hand motor dysfunction, pooled data from two trials showed that the risk of dTRA may be lower than that of TRA. In terms of hand sensory dysfunction, a pooled analysis of two studies showed that the incidence of numbness within 24 h postoperatively may be higher with dTRA than with TRA, but the incidence of persistent pain may be lower with dTRA than with TRA. Only one included study reported the incidence of nerve injury. Additionally, a pooled analysis of ten trials demonstrated that dTRA had a lower risk of radial artery occlusion (RAO) than TRA.ConclusionCompared with TRA, dTRA may be associated with a lower risk of hand clumsiness, persistent pain, RAO, and AVF, but a potentially higher incidence of hand numbness.

Objectives To compare feasibility and safety between ultrasound-guided and conventional distal transradial access (dTRA). Background Distal transradial access, a new technique for coronary angiography (CAG) and percutaneous coronary interventions (PCI), is safe and feasible and will become popular worldwide. Ultrasound-guided dTRA has been advocated to reduce failure rate and access-site complications. However, to date, the comparison of feasibility and safety between ultrasound-guided and conventional dTRA has not been reported. Method Overall, 137 patients (144 procedures) who underwent CAG or PCI using dTRA between September 2018 and February 2019 were investigated. These patients were classified into two groups: C (dTRA with conventional punctures; 76 patients, 79 procedures) and U (dTRA with ultrasound-guided punctures; 61 patients, 65 procedures) groups. Successful procedural rate, procedural outcomes, and complication rate during hospital stays were compared between the two groups. Results The procedural success rate was significantly higher in the U group than in the C group (97% vs. 87%, P=0.0384). However, the rate of PCI, puncture time, total fluoroscopy time, the volume of contrast medium, the rate of access-site ecchymosis, and incidence of nerve disorder were similar between the two groups. Additionally, radial artery occlusion after the procedure did not occur in this study. Conclusion The ultrasound-guided dTRA for CAG or PCI was associated with a lower failure rate than conventional dTRA. However, there were no significant differences in puncture time and complication rate between the two procedures.

Background Transradial access has become the primary route for coronary angiography (CAG) and percutaneous coronary interventions (PCI). Recently a new puncture site more distally on the dorsal side of the hand in the area of the anatomical snuffbox has been developed. Purpose With this multicenter registry, we wish to demonstrate the feasibility and safety of the distal transradial access (dTRA) and assess the rate of radial artery occlusion (RAO). As an exploratory endpoint, we compared peri-interventional data between right- and left-radial access and differences between the true anatomical snuffbox (SB) and the distal- dorsal (DD) puncture site. Methods Between December 2018 and May 2019 we included all patients into this registry with a planned CAG or PCI via dTRA in three cardiology centers in Germany. Procedural data, puncture success, crossover rate and complications were registered. We examined proximal and distal radial artery patency by ultrasound within 48 h after removal of compression device. Results A total of 327 patients were enrolled (mean age: 69 years, male: 69%), in 5 cases bilateral distal puncture was performed, puncture success was high (N=316/332, 95%) and the crossover rate was low (27/332, 8%). The rate of proximal (2/332) and distal (3/332) RAO was low. Major complications were not encountered. The comparison between SB and DD site and left- and right radial access showed no significant differences (see table). The indication for CAG in 50% of the population was acute coronary syndrome, including 28 patients with ST elevation myocardial infarction (8.4%). Overall PCI rate was 48%. PCI cases did not demonstrate a crossover rate higher than in CAG. PCI on chronic total occlusion (CTO) was performed in 16 cases including bilateral dTRA. Conclusion Coronary angiography and interventions via dTRA can be performed with a high rate of success and safety. This data suggests a reduced rate of RAO compared to previous reported data after cannulation via the standard forearm radial artery puncture site. Randomized studies are needed to further investigate these results. Funding Acknowledgement Type of funding source: None