Distal radial access – also known as the “snuffbox approach” – prevents radial artery occlusion (RAO) in the proximal segment after the procedure in comparison with conventional radial access, according to a study released Monday.
Observational studies have shown that distal radial access has a low rate of RAO, but this had not previously been compared against the standard proximal (conventional) approach in a randomized clinical trial.
Guering Edit-Lidt, MD, of Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, and co-investigators sought to compare the rate of proximal radial artery occlusion (PRAO) with Doppler ultrasound between distal and conventional radial access at 24 hours and 30 days after transradial coronary procedure. They reported their findings in a manuscript published in the Feb. 22 issue of JACC: Cardiovascular Interventions.
They conducted a prospective, comparative, longitudinal, randomized analysis. A total of 282 patients were randomized to either proximal radial access (n = 142) or distal radial access (n = 140) to evaluate the superiority of the distal approach in the prevention of PRAO with Doppler ultrasound 24 hours and 30 days after a transradial coronary procedure.
In the per-protocol analysis, the rates of PRAO at 24 hours and 30 days were 8.4% and 5.6% in the proximal group and 0.7% and 0.7% in the distal group, respectively (24 hours: odds ratio [OR]: 12.8; 95% confidence interval [CI]: 1.6 to 100.0; p = 0.002; 30 days: OR: 8.2; 95% CI: 1.0 to 67.2; p = 0.019). In the intention-to-treat analysis, the 24-hour and 30-day rates of PRAO were 8.8% and 6.4% for proximal radial access and 1.2% and 0.6% in the distal radial access group (24 hours: OR: 7.4; 95% CI: 1.6 to 34.3; p = 0.003; 30 days: OR: 10.6; 95% CI: 1.3 to 86.4; p = 0.007).
The authors concluded that the distal radial approach is superior to the proximal approach in preventing the RAO rates demonstrated with Doppler without increasing procedural time or vascular access-related complication rates. Despite the limitation of this analysis being performed at a single center, the findings are important. The authors added that the rate of RAO in the proximal approach seems to be associated not only with distal access site but also unfractionated heparin dose, hemostatic device type, hemostasis time and hemostatic compression level. Clinical trials are needed to prove the impact of these interventions on rates of RAO.
Ivo Bernat, MD, of Charles University, Pilsen, Czech Republic, wrote an accompanying editorial to this study. Bernat praised the analysis and gave a historical perspective of the evolution of distal radial access.
He concluded: “Although this single-center trial with a moderate number of randomized patients has obvious limitations to draw a general recommendation for the routine practice, it is necessary to highlight its importance. If these results are confirmed by the ongoing large international multicenter randomized DISCO Radial (DIStal Versus COnventional RADIAL Access for Coronary Angiography and Intervention) trial (NCT04171570), this will mean a significant next step in minimally invasive strategy, not only in percutaneous coronary catheterizations and interventions, but also for other endovascular procedures.”
Eid-Lidt G, Rivera Rodríguez A, Jimenez Castellanos J, et al. Distal Radial Artery Approach to Prevent Radial Artery Occlusion Trial. JACC Cardiovasc Interv 2021;14:378–85.
Bernat I. Distal Radial Approach: The Next Promising Step in an Even More Minimally Invasive Strategy. JACC Cardiovasc Interv 2021;14:386–7.