Optimizing distal radial access: clinical and anatomical predictors of failure from the multicenter DISTAL registry.

ABSTRACTIntroduction and objectives:Distal radial access (DRA) for coronary procedures is currently recognized as an alternative to conventional transradial access, with documented advantages primarily related to access-related complications. However, widespread adoption of DRA as the default approach remains limited. Therefore, this prospective cohort study aimed to present our initial experience with DRA for coronary procedures in any clinical settings.Methods:From August 2020 to November 2023, we included 1000 DRA procedures (943 patients) conducted at a single center. The study enrolled a diverse patient population. We recommended pre- and postprocedural ultrasound evaluations of the radial artery course, with ultrasound-guided DRA puncture. The primary endpoint was DRA success, while secondary endpoints included coronary procedure success, DRA performance metrics, and the incidence of access-related complications.Results:The DRA success rate was 97.4% (n = 974), with coronary procedure success at 96.9% (n = 969). The median DRA time was 40 [interquartile range, 30-60] seconds. Diagnostic procedures accounted for 64% (n = 644) of cases, while 36% (n = 356) involved percutaneous coronary intervention (PCI), including primary PCI in 13% (n = 128). Pre-procedure ultrasound evaluation and ultrasound-guided DRA were performed in 83% (n = 830) and 85% (n = 848) of cases, respectively. Access-related complications occurred in 2.9% (n = 29).Conclusions:This study shows the safety and feasibility of DRA for coronary procedures, particularly when performed under ultrasound guidance in a diverse patient population. High rates of successful access and coronary procedure outcomes were observed, together with a low incidence of access-related complications. The study was registered on ClinicalTrials.gov (NTC06165406).

ABSTRACTIntroduction and objectives:Distal radial access (DRA) for coronary procedures is currently recognized as an alternative to conventional transradial access, with documented advantages primarily related to access-related complications. However, widespread adoption of DRA as the default approach remains limited. Therefore, this prospective cohort study aimed to present our initial experience with DRA for coronary procedures in any clinical settings.Methods:From August 2020 to November 2023, we included 1000 DRA procedures (943 patients) conducted at a single center. The study enrolled a diverse patient population. We recommended pre- and postprocedural ultrasound evaluations of the radial artery course, with ultrasound-guided DRA puncture. The primary endpoint was DRA success, while secondary endpoints included coronary procedure success, DRA performance metrics, and the incidence of access-related complications.Results:The DRA success rate was 97.4% (n = 974), with coronary procedure success at 96.9% (n = 969). The median DRA time was 40 [interquartile range, 30-60] seconds. Diagnostic procedures accounted for 64% (n = 644) of cases, while 36% (n = 356) involved percutaneous coronary intervention (PCI), including primary PCI in 13% (n = 128). Pre-procedure ultrasound evaluation and ultrasound-guided DRA were performed in 83% (n = 830) and 85% (n = 848) of cases, respectively. Access-related complications occurred in 2.9% (n = 29).Conclusions:This study shows the safety and feasibility of DRA for coronary procedures, particularly when performed under ultrasound guidance in a diverse patient population. High rates of successful access and coronary procedure outcomes were observed, together with a low incidence of access-related complications. The study was registered on ClinicalTrials.gov (NTC06165406).

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. The aim of this study was to assess the superiority of DRA compared with conventional TRA with respect to forearm RAO. 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. 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 153minutes; 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. 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.

ABSTRACTBackgroundTraditional transradial access (TRA) is widely used for coronary and non‐coronary interventions with significant improvements in procedural outcomes; however, it is associated with RAO that precludes repeat use of the same artery for possible future TRI and other purposes. Distal radial access (DRA) has been proposed as an effective alternative to decrease RAO rates. Published literature describing the RAO rate after DRA versus TRA from various RCT and clinical registries has shown conflicting results.ObjectivesThis study compared the forearm radial artery occlusion (RAO) rate assessed by Doppler ultrasound between distal and conventional radial access at 1‐year follow‐up after the initial procedure.MethodsTENDERA was a multicenter, randomized controlled study comparing DRA versus TRA for coronary diagnostic and interventional procedures using 5 or 6F hydrophilic‐coated sheaths. The primary endpoint was forearm RAO at 12 months after radial access. The secondary endpoints included puncture time, sheath insertion and total procedure time, radiation dose, and vascular access site‐related complications.ResultsEight hundred and fifty patients were randomized to either TRA (n = 418) and DRA (n = 432) groups. In the intention‐to‐treat analysis, the rate of forearm RAO at 12 months was observed in 39 patients (4.6%) and was significantly reduced in the DRA group compared with the TRA group (2.5% vs. 6.7%, RR 2.59 [95% CI 1.29–5.59], p = 0.010). Analysis in per protocol population has shown consistent results with forearm RAO rate 2.8% in the DRA group versus 6.5% in the TRA group (p = 0.008). The crossover rate was higher (4.6% vs. 1%, p = 0.013) and median hemostasis time was shorter (156.5 min vs. 180 min, p < 0.001) with DRA. Overall bleeding (BARC 1–2) and postprocedure hematoma > 5 cm occurred less frequently in the DRA group compared with the TRA group (3.2% vs. 20.5%, p < 0.001% and 9.0% vs. 27.0%, p < 0.001, respectively). No significant differences were observed in total procedure time and radiation dose between groups.ConclusionsDRA for coronary diagnostic and interventional procedures is associated with reduced forearm RAO rate and shorter hemostasis time, but a longer sheath insertion time and higher crossover rate compared with TRA.Trial RegistrationClinicalTrials.gov: NCT04211584.

Aim. To evaluate immediate and medium-term (3 months) results of safety and effectiveness of distal versus proximal radial access for coronary interventions.Material and methods. An analysis of 776 patients of the prospective randomized TENDERA trial was performed: distal radial access (DRA) group — 1391 patients; proximal radial access (PRA) group — 385 patients. After excluding patients with failed primary access, the primary sample sizes decreased (DRA — 371, PRA — 382). Access-site crossover rate was statistically higher in the DRA group (5,1% and 0,8%, p&lt;0,001). The primary endpoint was immediate (inhospital) or long-term radial artery (RA) thrombosis/occlusion. There were following secondary endpoints: 1 — composite endpoint including complications from the access artery; 2 — access parameters.Results. Significant differences were obtained for the primary endpoint: DRA 2,7% (n=10), PRA 6,8% (n=26), p=0,008. Distal RA occlusion with patent RA: DRA: 1,3% (n=5), PRA: 0 (n=0), p=0,023. The secondary composite point showed significant differences in the following groups of complications: BARC type I bleeding (DRA: 3,8% (n=14), PRA: 21,7% (n=83), p&lt;0,001); hematoma &gt;5 cm on day 1 (DRA: 10% (n=37), PRA: 25,9% (n=98), p&lt;0,001); hematoma &gt;5 cm on day 7 (DRA: 12,4% (n=45), PRA: 34,6% (n=132), p&lt;0,001). The following access parameters showed significant differences: distal RA puncture time — 19,0 (8,0; 50), proximal RA puncture time — 13,5 (5,0; 29), p&lt;0,001; introducer insertion by DRA 42,0 (26,0; 84,0), PRA 35,0 (23,0; 55,0), p&lt;0,001; duration of access artery hemostasis (min): DRA 180,0 (120,0; 480,0), PRA 155,0 (115,0; 195,0), p&lt;0,001. Duration of the procedure and fluoroscopy, radiation dose, and RA spasm in both groups did not have significant differences.Conclusion. In the TENDERA study, DRA demonstrated efficacy and safety in interventional coronary procedures compared to PRA in the mid-term follow-up period — significantly lower incidence of RA occlusions and local complications.

Objective: to study the effectiveness of the distal radial artery access in the treatment of complications after ulnar artery catheterization. Material and methods. We analyze the outcomes of 1558 catheterizations of the ulnar arteries. Less than 1% of local hemorrhagic complications and 1.5% of post-catheterization occlusions of the ulnar artery were revealed after ulnar artery catheterization, Results. One half of the patients with hemorrhagic complications after ulnar artery catheterization underwent conservative treatment (mechanical compression of the site of complication), the rest of patients underwent surgical treatment. Positive effect was achieved in all patients who underwent endovascular treatment for post-catheterization hemorrhagic complications. In 50% of cases, recanalization of post-catheterization ulnar artery occlusion via the distal radial access was effective. In 1 patient after recanalization of post-catheterization ulnar artery occlusion using the distal radial artery access, the occlusion of radial artery in wrist segment occurred, with preserved blood flow in radial artery of the forearm. Conclusion. Distal radial artery access for correction of post-catheterization complications in ulnar artery is a feasible and safe method. Keywords: distal radial access, ulnar artery, radial artery, occlusion

Transradial access (TRA) has become the default access method for coronary diagnostic and interventional procedures. As compared to transfemoral access, TRA has been shown to be safer, cost-effective and more patient-friendly. Radial artery occlusion (RAO) represents the most frequent complication of TRA, and precludes future coronary procedures through the radial artery, the use of the radial artery as a conduit for coronary artery bypass grafting or as arteriovenous fistula for patients on hemodialysis. Recently, distal radial access (DRA) has emerged as a promising alternative to TRA, yielding potential for minimizing the risk of RAO. However, an international multicenter randomized comparison between DRA, and conventional TRA with respect to the rate of RAO is still lacking. DISCO RADIAL is a prospective, multicenter, open-label, randomized, controlled, superiority trial. A total of 1300 eligible patients will be randomly allocated to undergo coronary angiography and/or percutaneous coronary intervention (PCI) through DRA or TRA using the 6 Fr Glidesheath Slender sheath introducer. Extended experience with both TRA and DRA is required for operators' eligibility and optimal evidence-based best practice to reduce RAO systematically implemented by protocol. The primary endpoint is the incidence of forearm RAO assessed by vascular ultrasound at discharge. Several important secondary endpoints will also be assessed, including access-site cross-over, hemostasis time, and access-site related complications. The DISCO RADIAL trial will provide the first large-scale multicenter randomized evidence comparing DRA to TRA in patients scheduled for coronary angiography or PCI with respect to the incidence of RAO at discharge.

In 2015, The European Society of Cardiology for Acute Coronary Syndrome recommended that Class I use radial as the preferred access method for any percutaneous coronary intervention regardless of clinical presentation. However, the use of TRA is associated with some complications: radiation artery occlusion (RAO) (The reported incidence of RAO is highly variable in the range of 2-11%, radial arterial spasm, radial arterial perforation, radial artery pseudoaneurysm, arteriovenous fistula, bleeding, nerve damage, and complex regional pain syndrome. Limited data are available regarding the technique of distal radial access, complications, and potential benefits. The purpose of our study is to compare the incidence of radial artery occlusion between distal radial and conventional radial access. The study included 292 patients (who underwent percutaneous coronary intervention)in who is felt pulsations at the site of a puncture of the radial artery. Patients were followed one month after the procedure, with Doppler ultrasonography or access from the same artery. After a month, the occlusion of the radial artery occurred in 8 (5.7%) patients in conventional radial access, there was no occlusion of the radial artery in the distal radial access group. This investigation shows that distal radial access is associated with a lower incidence of occlusion of the radial artery.

Crossover patterns and temporal trends in distal vs conventional radial access: Meta-analysis of randomized trials.

Introduction: Distal radial access (dRA) has recently gained global popularity as an alternative access route for vascular procedures. Among the benefits of dRA are the low risk of entry site bleeding complications, the low rate of radial artery occlusion, and improved patient and operator comfort. The aim of this large multicenter registry was to demonstrate the feasibility and safety of dRA in a wide variety of routine procedures in the catheterization laboratory, ranging from coronary angiography and percutaneous coronary intervention to peripheral procedures. Methods: The study comprised 1240 patients who underwent coronary angiography, PCI or noncoronary procedures through dRA in two Hungarian centers from January 2019 to April 2021. Baseline patient characteristics, number and duration of arterial punctures, procedural success rate, crossover rate, postoperative compression time, complications, hospitalization duration, and different learning curves were analyzed. Results: The average patient age was 66.4 years, with 66.8% of patients being male. The majority of patients (74.04%) underwent a coronary procedure, whereas 25.96% were involved in noncoronary interventions. dRA was successfully punctured in 97% of all patients, in all cases with ultrasound guidance. Access site crossover was performed in 2.58% of the patients, mainly via the contralateral dRA. After experiencing 150 cases, the dRA success rate plateaued at >96%. Our dedicated dRA step-by step protocol resulted in high open radial artery (RA) rates: distal and proximal RA pulses were palpable in 99.68% of all patients at hospital discharge. The rate of minor vascular complications was low (1.5%). A threshold of 50 cases was sufficient for already skilled radial operators to establish a reliable procedural method of dRA access. Conclusion: The implementation of distal radial artery access in the everyday routine of a catheterization laboratory for coronary and noncoronary interventions is feasible and safe with an acceptable learning curve.

Distal radial access (DRA) is a well-tolerated and effective alternative to traditional radial access (TRA) for coronary procedures. However, the comparative value of these modalities remains unknown in the emergency setting, particularly in patients with ST-elevation myocardial infarction (STEMI). To compare DRA versus TRA for emergency coronary procedures through a meta-analysis. We systematically searched PubMed , Embase , and Cochrane databases to identify studies comparing DRA versus TRA in patients undergoing emergency coronary angiography (CAG) or percutaneous coronary intervention (PCI). All statistical analyses were performed using R software version 4.3.1 with a random-effects model. We included four studies comprising 543 patients undergoing emergency CAG or PCI, of whom 447 (82.3%) had STEMI. As compared with TRA, DRA was associated with lower radial artery occlusion rates (RR, 0.21; 95% CI, 0.06-0.72) and shorter hemostasis time (MD, -4.23 h; 95% CI, -6.23 to 2.13). There was no significant difference between modalities in terms of puncture failure (RR, 1.38; 95% CI, 0.31-6.19), crossover access (RR, 1.37; 95% CI, 0.42-4.44), puncture time (SMD, 0.33; 95% CI, -0.16 to 0.81), procedure time (MD, 0.97 min; 95% CI, -5.19 to 7.13), or rates of cannulation success (RR, 0.94; 95% CI, 0.83-1.06). In terms of other periprocedural complications, there were no differences between both groups. These findings remained consistent in a subgroup analysis of patients with STEMI. In this meta-analysis, DRA was superior to TRA in terms of radial artery occlusion and hemostasis time, with similar rates of periprocedural complications.

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. The aim of this study was to compare safety, efficacy and feasibility of DRA to PRA. 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. 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). 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.

Radiation Exposure to Operators in Coronary Procedures Between Left Distal and Right Conventional Radial Access.

Distal Radial Artery Approach to Prevent Radial Artery Occlusion Trial.

Distal radial access (DRA) through the anatomical snuff-box is a novel technique for coronary procedures. Emerging evidence suggests that DRA is associated with a lower risk of certain complications compared to proximal radial access (PRA). A systematic review was conducted to compare clinical and procedural outcomes between both access sites for coronary angiography and percutaneous coronary intervention. We searched PubMed , Web of Science , Cochrane , and Scopus to identify relevant randomized controlled trials. We included 23 randomized controlled trials enrolling 10 062 patients (DRA group: 5042; PRA group: 5020) in this review. DRA was associated with a lower risk for radial artery occlusion (RAO) at the longest reported follow-up [risk ratio (RR): 0.30, P < 0.00001], in-hospital RAO (RR: 0.28, P < 0.00001), any bleeding (RR: 0.40, P = 0.04), hand clumsiness (RR: 0.05, P < 0.00001), and shorter time to hemostasis [mean difference (MD): -40.93, P < 0.00001]. However, DRA showed a higher access failure rate (RR = 2.64, P < 0.00001), longer access time (MD = 0.77, P < 0.00001), more puncture attempts (MD: 0.60, P < 0.0001), and greater access-related pain [standardized mean difference (SMD) = 0.23, P = 0.02]. Both approaches were comparable in terms of major adverse cardiac events (RR = 0.74, P = 0.60), and hand function (SMD = -0.05, P = 0.68). DRA is a safe alternative to PRA for coronary procedures, with a lower risk of complications, including RAO. However, it is limited by access-related challenges.