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Optimizing distal radial access: clinical and anatomical predictors of failure from the multicenter DISTAL registry
Kristian Rivera1,2, Diego Fernández-Rodríguez1,2, Juan Bullones3
1Department of Cardiology, Arnau de Vilanova University Hospital.
Insights
Distal radial access (DRA) is a safe and effective technique for coronary procedures. Arterial pulse strength, ultrasound guidance, and operator experience are key factors for successful DRA, minimizing complications.
Area of Science:
- Cardiology
- Vascular Access
- Interventional Procedures
Background:
- Distal radial access (DRA) offers advantages over conventional transradial access for coronary procedures, including reduced vascular complications and improved patient comfort.
- Predictors of DRA failure require further definition to optimize its clinical application.
- This study evaluates the feasibility, safety, and predictors of DRA failure in a broad patient population.
Purpose of the Study:
- To assess the feasibility and safety of distal radial access (DRA) in an all-comer population undergoing coronary procedures.
- To identify independent predictors of DRA failure and success.
- To develop an evidence-based strategy for optimizing DRA procedural outcomes.
Main Methods:
- A prospective multicenter cohort study included 1387 patients undergoing 1454 coronary procedures via DRA.
- Multivariate logistic regression and conditional inference trees (CITs) were employed to identify predictors of failure.
- Data were collected between August 2020 and September 2024.
Main Results:
- DRA demonstrated a high success rate (96.5%), with 99% of procedures completed successfully.
- Access-related complications were low (2.5%), including 0.8% in-hospital radial artery occlusion.
- Weak distal radial pulse was the strongest predictor of failure (OR: 10.07), while preprocedural ultrasound (US) evaluation, US-guided puncture, right-sided access, and operator experience predicted success. US guidance significantly improved outcomes in patients with weak pulses (98.2% vs. 61.0%).
Conclusions:
- Distal radial access (DRA) is a safe, feasible, and effective strategy for coronary procedures.
- Procedural success is significantly influenced by arterial pulse strength, ultrasound guidance, and operator experience.
- A CIT-derived framework offers a practical approach to optimize access site selection and enhance procedural outcomes.
Background:
Distal radial access (DRA) is a promising alternative to conventional transradial access for coronary procedures, offering fewer vascular complications, shorter hemostasis, and greater patient comfort. However, the predictors of DRA failure remain insufficiently defined. This study aimed to evaluate the feasibility, safety, and predictors of DRA failure in an all-comer population and to develop an evidence-based strategy to optimize procedural success.
Methods:
A prospective multicenter cohort included 1387 patients who underwent 1454 coronary procedures through DRA between August 2020 and September 2024. Multivariate logistic regression and conditional inference trees (CITs) were used to identify and visualize independent predictors of failure.
Results:
DRA was successful in 96.5% of cases, with 99% of coronary procedures completed through the initial access. Access-related complications were infrequent (2.5%), including 0.8% inhospital radial artery occlusion. Weak distal radial pulse was the strongest independent predictor of failure (odds ratio: 10.07, 95% confidence interval: 5.22-20.21; P < 0.001), while preprocedural ultrasound (US) evaluation, US-guided puncture, right-sided access, and operator experience independently predicted success. US guidance markedly improved outcomes in patients with weak pulses (98.2% vs. 61.0%; P < 0.001). The learning curve plateaued after 60 cases.
Conclusion:
DRA is a safe, feasible, and effective access strategy for coronary procedures in an all-comer population. The success of the procedure depends on the strength of the arterial pulse, the US guidance, and the experience of the operator. The CIT-derived evidence-based framework provides a practical and reproducible approach to optimize access-site selection and improve procedural outcomes.
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