Distal radial access (DRA) lowered the risks of radial artery occlusion (RAO) and EASY (Early Discharge After Transradial Stenting of Coronary Arteries) grade ≥II hematoma but was associated with longer duration for radial artery cannulation and sheath insertion, more attempts and a higher rate of access-site crossover compared to conventional radial access (RA), according to the new meta-analysis.

Giuseppe Ferrante, MD, PhD, of Humanitas University, Pieve Emanuele, and IRCCS-Humanitas Research Hospital, Rozzano, both in Italy, and colleagues reported these findings in a manuscript published Monday online and in the Nov. 28 issue of JACC: Cardiovascular Interventions.

The meta-analysis comprised 14 randomized controlled trials, of which nine were published as full papers and five were presented as abstracts at conferences.

The primary endpoint was the occurrence of forearm RAO at the longest available follow-up. The rate of RAO was reported in all studies except one.

Heterogeneity varied among various endpoints and was low for EASY grade ≥II hematoma, moderate in RAO outcomes and high for other outcomes. No publication bias was detected with respect to the primary endpoint.  

The use of DRA, compared to conventional RA, was associated with a lower risk of RAO at latest follow-up ranging from 1 to 60 days (relative risk [RR]: 0.36; 95% confidence interval [CI]: 0.23 to 0.56; p<0.001; number needed to treat for an additional beneficial outcome [NNTB]=30), in-hospital RAO (RR: 0.32; 95% CI: 0.19 to 0.53; p<0.001; NNTB =28), and EASY ≥ II hematoma (RR: 0.51; 95% CI: 0.27 to 0.96; p=0.04; NNTB =107). However, DRA use demonstrated significant higher time for radial artery puncture (standardized mean difference [SMD]: 3.56; 95% CI: 0.96 to 6.16; p<0.001) and for sheath insertion (SMD: 0.37; 95% CI: 0.16 to 0.58; p<0.01), a higher number of puncture attempts (SMD: 0.59, 95% CI: 0.48 to 0.69; p<0.001), and a higher risk of access-site crossover (RR: 3.08; 95% CI: 1.88 to 5.06; p<0.001; NNT for an additional harmful outcome = 12). Fluoroscopy time and contrast volume were comparable between the two groups.

Further, a meta-regression analyses showed increasing age in the conventional RA group was associated with a reduced effect of DRA, versus conventional RA, on the risk of RAO at the longest follow up.

The major limitations of the meta-analysis were different baseline patient population, trial designs, endpoint definitions and duration of follow up of included studies.

In an accompanying editorial, Matthew I. Tomey, MD, and Jacqueline E. Tamis-Holland, MD, of the Icahn School of Medicine at Mount Sinai, New York, stated that while the current meta-analysis results challenge the interventional community to overcome the DRA learning curve, the key question remains whether reduced RAO and EASY grade ≥II hematomas justifies it. They added that the identification of patients the benefit from DRA falls beyond the scope of a study-level meta-analysis. Dedicated trials are required before DRA can be endorsed as a strategy of choice for acute coronary syndrome, they wrote.

Sources:

Ferrante G, Condello F, Rao SV, et al. Distal vs Conventional Radial Access for Coronary Angiography and/or Intervention: A Meta-Analysis of Randomized Trials. JACC Cardiovasc Interv. 2022;15:2297–2311.

Tomey MI, Tamis-Holland JE. Distal Radial Artery Access: Fad or New Frontier? . JACC Cardiovasc Interv. 2022;15:2312–2314.

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