Distal radial artery access in the anatomical snuffbox for coronary angiography and percutaneous coronary intervention

Abstract

Objective: Compared with transfemoral access, transradial access (TRA) has been shown to reduce major adverse cardiac events, major bleeding, and access site-related vascular complications. This study aimed to investigate the safety and feasibility of the novel distal TRA in the anatomical snuffbox (AS) for coronary angiography and percutaneous coronary intervention (PCI).
Materials and methods: This cross-sectional study included a total of 102 consecutive patients (67 male; mean age: 56.1±13.2 years) who underwent coronary angiography and/or PCI via distal TRA in the AS.
Results: Distal TRA was successfully performed in 98% of the patients. The crossover rate was very low (2%). The right distal TRA was the preferred approach and was used in 90.2% of the patients. Mean artery puncture time was 3.9±1.6 min. Mean compression time to achieve hemostasis at puncture site was 17.0±6.9 min. The post-procedural hematoma rate was very low (1%). One-month follow-up Doppler ultrasound showed zero cases of arteriovenous fistula and pseudo-aneurysm. However, proximal radial artery occlusion was observed in 1 patient (1%) and it was asymptomatic. Artery puncture time, unfractionated heparin dose, time to sheath removal, procedural numerical rating scale (NRS) score and post-procedural NRS score at 6 h were significantly different between diagnostic catheterization and PCI procedures (p<0.001).
Conclusion: The distal TRA in the AS is safe and feasible for coronary angiography and PCI. However, further studies are warranted.

Keywords

• Anatomical snuffbox
• coronary angiography
• distal transradial access
• percutaneous coronary intervention

Koroner anjiyografi ve perkütan koroner girişimlerde, anatomik enfiye çukurundan distal radyal arter girişimi

Öz

Amaç: Transfemoral erişim ile karşılaştırıldığında, transradyal erişimin majör advers kardiyak olayları, majör kanamayı ve girişim bölgesine bağlı vasküler komplikasyonları azalttığı gösterilmiştir. Bu çalışmada koroner anjiyografi ve perkütan koroner girişim için anatomik enfiye çukurundaki distal transradyal erişimin güvenilirliği ve fizibilitesi araştırıldı.
Gereç ve yöntem: Bu kesitsel çalışmaya anatomik enfiye çukurundaki distal transradyal erişim yoluyla yapılan koroner anjiyografi ve/veya perkütan koroner girişim uygulanan toplam 102 ardışık hasta (67 erkek, ortalama yaş: 56,1±13,2 yıl) dahil edildi.
Bulgular: Hastaların %98'inde distal transradyal erişim başarıyla gerçekleştirildi. Başarısızlık oranı çok düşüktü (%2). Sağ distal transradyal erişim tercih edilen yaklaşımdı ve hastaların %90,2'sinde kullanıldı. Ortalama arter ponksiyon süresi 3,9±1,6 dakika idi. Ponksiyon bölgesinde hemostaz elde etmek için ortalama kompresyon süresi 17,0±6,9 dakika idi. İşlem sonrası hematom oranı çok düşüktü (%1). Bir aylık takipte Doppler ultrasonografide arteriyovenöz fistül ve/veya psödo-anevrizma saptanmadı. Ancak 1 hastada (%1) proksimal radyal arter oklüzyonu izlendi ve asemptomatik seyretti. Arter ponksiyon süresi, fraksiyone olmayan heparin dozu, kılıf çıkarılma süresi, işlem sırasındaki NRS skoru ve işlemden 6 saat sonraki NRS skoru tanısal kateterizasyon ve perkütan koroner girişim prosedürleri arasında anlamlı olarak farklıydı (p<0,001).
Sonuç: Anatomik enfiye çukurundaki distal transradyal erişim koroner anjiyografi ve perkütan koroner girişim için güvenli ve uygulanabilirdir. Bununla birlikte, bu teknik için daha fazla araştırma gerekmektedir.

Anahtar Kelimeler

• anatomical snuffbox
• coronary angiography
• distal transradial access
• percutaneous coronary intervention

Kaynakça

1. 1. Thiele H, Desch S, de Waha S. [Acute myocardial infarction in patients with ST-segment elevation myocardial infarction : ESC guidelines 2017]. Herz 2017;42:728-38.
2. 2. Mamas MA, Anderson SG, Carr M, Ratib K, Buchan I, Sirker A, et al. Baseline bleeding risk and arterial access site practice in relation to procedural outcomes after percutaneous coronary intervention. J Am Coll Cardiol 2014;64:1554-64.
3. 3. Bertrand OF, Bernat I. Radial artery occlusion: still the Achille's heel of transradial approach or is it? Coron Artery Dis 2015;26:97-8.
4. 4. Mamas MA, Fraser DG, Ratib K, Fath-Ordoubadi F, El-Omar M, Nolan J, et al. Minimising radial injury: prevention is better than cure. EuroIntervention 2014;10:824-32.
5. 5. Abdelaal E, Brousseau-Provencher C, Montminy S, Plourde G, MacHaalany J, Bataille Y, et al. Risk score, causes, and clinical impact of failure of transradial approach for percutaneous coronary interventions. JACC Cardiovasc Interv 2013;6:1129-37.
6. 6. Ratib K, Mamas MA, Anderson SG, Bhatia G, Routledge H, De Belder M, et al. Access site practice and procedural outcomes in relation to clinical presentation in 439,947 patients undergoing percutaneous coronary intervention in the United kingdom. JACC Cardiovasc Interv 2015;8:20-9.
7. 7. Bertrand OF, Rao SV, Pancholy S, Jolly SS, Rodes-Cabau J, Larose E, et al. Transradial approach for coronary angiography and interventions: results of the first international transradial practice survey. JACC Cardiovasc Interv 2010;3:1022-31.
8. 8. Rao SV, Cohen MG, Kandzari DE, Bertrand OF, Gilchrist IC. The transradial approach to percutaneous coronary intervention: historical perspective, current concepts, and future directions. J Am Coll Cardiol 2010;55:2187-95.

9. 9. Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37:267-315.
10. 10. Kiemeneij F. Left distal transradial access in the anatomical snuffbox for coronary angiography (ldTRA) and interventions (ldTRI). EuroIntervention 2017;13:851-7.
11. 11. Hallett S, Ashurst JV. Anatomy, Shoulder and Upper Limb, Hand Anatomical Snuff Box. In: StatPearls. Treasure Island (FL); 2020.
12. 12. Aoi S, Htun WW, Freeo S, Lee S, Kyaw H, Alfaro V, et al. Distal transradial artery access in the anatomical snuffbox for coronary angiography as an alternative access site for faster hemostasis. Catheter Cardiovasc Interv 2019;94:651-7.
13. 13. Naito T, Sawaoka T, Sasaki K, Iida K, Sakuraba S, Yokohama K, et al. Evaluation of the diameter of the distal radial artery at the anatomical snuff box using ultrasound in Japanese patients. Cardiovasc Interv Ther 2019;34:312-6.
14. 14. Lee JW, Park SW, Son JW, Ahn SG, Lee SH. Real-world experience of the left distal transradial approach for coronary angiography and percutaneous coronary intervention: a prospective observational study (LeDRA). EuroIntervention 2018;14:e995-e1003.
15. 15. Al-Azizi KM, Grewal V, Gobeil K, Maqsood K, Haider A, Mohani A, et al. The Left Distal Transradial Artery Access for Coronary Angiography and Intervention: A US Experience. Cardiovasc Revasc Med 2019;20:786-9.
16. 16. Shah RM, Patel D, Abbate A, Cowley MJ, Jovin IS. Comparison of transradial coronary procedures via right radial versus left radial artery approach: A meta-analysis. Catheter Cardiovasc Interv 2016;88:1027-33.
17. 17. Stella PR, Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty. Cathet Cardiovasc Diagn 1997;40:156-8.
18. 18. Sanmartin M, Gomez M, Rumoroso JR, Sadaba M, Martinez M, Baz JA, et al. Interruption of blood flow during compression and radial artery occlusion after transradial catheterization. Catheter Cardiovasc Interv 2007;70:185-9.
19. 19. Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv 2008;72:335-40.
20. 20. Cubero JM, Lombardo J, Pedrosa C, Diaz-Bejarano D, Sanchez B, Fernandez V, et al. Radial compression guided by mean artery pressure versus standard compression with a pneumatic device (RACOMAP). Catheter Cardiovasc Interv 2009;73:467-72.
21. 21. Chugh SK, Chugh S, Chugh Y, Rao SV. Feasibility and utility of pre-procedure ultrasound imaging of the arm to facilitate transradial coronary diagnostic and interventional procedures (PRIMAFACIE-TRI). Catheter Cardiovasc Interv 2013;82:64-73.
22. 22. Garg N, Madan BK, Khanna R, Sinha A, Kapoor A, Tewari S, et al. Incidence and predictors of radial artery occlusion after transradial coronary angioplasty: Doppler-guided follow-up study. J Invasive Cardiol 2015;27:106-12.
23. 23. Saito S, Ikei H, Hosokawa G, Tanaka S. Influence of the ratio between radial artery inner diameter and sheath outer diameter on radial artery flow after transradial coronary intervention. Catheter Cardiovasc Interv 1999;46:173-8.
24. 24. Pancholy SB. Comparison of the effect of intra-arterial versus intravenous heparin on radial artery occlusion after transradial catheterization. Am J Cardiol 2009;104:1083-5.