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Feasibility and Safety of the Routine Distal Transradial Approach in the Anatomical Snuffbox for Coronary Procedures:
Łukasz Koziński1, Zbigniew Orzałkiewicz1, Alicja Dąbrowska-Kugacka2
1Department of Cardiology, Chojnice Specialist Hospital, Lesna 10, 89-600 Chojnice, Poland.
Insights
The distal transradial approach (dTRA) is less favorable than the conventional transradial access (cTRA) for coronary procedures, showing higher complication rates. Patients with diabetes are particularly at risk for dTRA complications.
Area of Science:
- Cardiology
- Vascular Access Techniques
- Interventional Cardiology
Background:
- The distal transradial approach (dTRA) is a novel technique for coronary procedures, hypothesized to improve upon the conventional transradial access (cTRA).
- Assessing the safety and efficacy of dTRA compared to cTRA is crucial for optimizing patient outcomes in interventional cardiology.
Purpose of the Study:
- To prospectively evaluate the safety and efficacy of the distal transradial approach (dTRA) versus the conventional transradial access (cTRA) in patients undergoing coronary procedures.
- To compare primary and secondary endpoints, including access crossover, access-related complications, major adverse cardiovascular events (MACE), and clinical success rates between dTRA and cTRA.
Main Methods:
- A prospective, single-center, randomized trial involving 400 Caucasian patients (465 initially screened) comparing dTRA and cTRA.
- Clinical and ultrasound follow-ups were conducted at 24 hours and 60 days post-procedure.
- Primary endpoint: combined access crossover, access-related complications, and MACE. Secondary endpoints: clinical success, access-site complications, and MACE at 60 days.
Main Results:
- The primary endpoint occurred significantly more often with dTRA (OR: 2.31, p=0.001), driven by higher access crossover and longer access times.
- Radial artery spasm was more frequent with dTRA (19% vs. 4.5%, p<0.0001), alongside increased physical discomfort and transient thumb numbness.
- Early and mid-term radial artery occlusion rates were comparable between dTRA and cTRA (2.5% vs. 3%, p=0.98).
- Diabetes independently predicted a higher incidence of the primary endpoint with dTRA (OR: 18.67).
Conclusions:
- The distal transradial approach (dTRA) is less favorable than conventional transradial access (cTRA) for routine coronary procedures due to increased arterial spasm and access crossover.
- While most local complications with dTRA were minor, individuals with diabetes exhibited a significantly higher susceptibility to these complications.
- dTRA necessitates further refinement to mitigate its drawbacks, particularly in diabetic patient populations.
Abstract:
The distal transradial approach (dTRA) through the anatomical snuffbox is hypothesized to offer greater benefits than the conventional transradial access (cTRA) for patients undergoing coronary procedures. Our goal was to assess the safety and efficacy of dTRA. Out of 465 consecutive Caucasian patients, 400 were randomized (1:1) to dTRA or cTRA in a prospective single-center trial. Clinical and ultrasound follow-ups were obtained at 24 h and 60 days post-procedure. The primary combined endpoint consisted of access crossover, access-related complications, and major adverse cardiovascular events (MACE). Secondary endpoints included clinical success endpoints (puncture success, crossover, and access time), access-site complications endpoints, and MACE at 60 days. The primary endpoint was significantly higher in the dTRA [odds ratio (OR): 2.31, 95% confidence interval (CI): 1.38-3.86, p = 0.001]. Clinical success endpoints, namely crossover (10% vs. 3.5%, p < 0.05) and access-time [median: 140s (85-322) vs. 80s (58-127), p < 0.001], did not favor the dTRA, despite a similar success rate in radial artery puncture between the dTRA and cTRA (99.5% vs. 99%). Radial artery spasm (19% vs. 4.5%, p < 0.0001), physical discomfort during access, and transient thumb numbness after the procedure occurred more frequently with the dTRA. However, early (2.5% vs. 4.5%, p = 0.41) and mid-term (2.5% vs. 3%, p = 0.98) forearm radial artery occlusion rates were comparable between the dTRA and cTRA. Randomization to the dTRA, lower forearm radial pulse volume, higher body mass index, and lower body surface area independently predicted the primary endpoint in multivariate analysis. In the interaction effect analysis, only diabetes increased the incidence of the primary endpoint with the dTRA (OR: 18.67, 95% CI: 3.96-88.07). The dTRA was a less favorable strategy than cTRA during routine coronary procedures due to a higher incidence of arterial spasm and the necessity for access crossover. The majority of local complications following the dTRA were clinically minor complications. Individuals with diabetes were particularly susceptible to complications associated with the dTRA.
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