Coronary procedures via distal transradial access in older as compared with non-older patients: Insights from the DISTRACTION registry.

BACKGROUND: Older patients are at a higher risk of access site complications and bleeding. Systematic reviews and meta-analysis have highlighted the benefits of distal over proximal transradial access (mainly, lower rates of radial artery occlusion and faster hemostasis). We aimed to evaluate the feasibility and safety of distal transradial access (dTRA) for routine coronary procedures in older patients compared with non-older patients. METHODS: Retrospective analysis of a large and real-world sample of 5524 consecutive all-comers patients who underwent coronary procedures via dTRA were included in the DISTRACTION registry. RESULTS: In the older patients (greater than or equal to 65 years) group (n = 2594, 47%), there were higher rates of hypertension (83% vs 71.1%; P less than .0001), diabetes (45.1% vs 34.7%; P less than .0001), previous stroke (2.9% vs 2%; P=.0425), chronic heart failure (9.2% vs 7.1%; P=.0040), severe aortic valvar disease (4.2% vs 2.9%; P=.0070), chronic kidney disease stages 3 and 4 (8.1% vs 3.1%; P less than .0001), previous percutaneous coronary intervention (27.2% vs 24.5%; P=.0253), previous coronary artery bypass grafting (5.1% vs 2.2%; P less than .0001), cardiogenic shock at presentation (1.3% vs 0.4%; P=.0003), rotational atherectomy (0.7% vs 0.2%; P=.0050), and left main percutaneous coronary intervention (2.7% vs 1.5%; P=.0033). No significant differences were observed in the rates of access site crossovers. No major adverse cerebrovascular and cardiac events directly related to dTRA, no hand/thumb dysfunction or ischemia after any procedure, and no access site-related hematomas (early discharge after transradial stenting of coronary arteries greater than or equal to 2) were recorded. CONCLUSIONS: Despite more comorbidities, more complex coronary disease, and more challenging presentation, the adoption of dTRA as the default approach for routine coronary procedures in older patients, by proficient operators, appears to be safe and feasible.

Distal transradial access for coronary procedures: a prospective cohort of 3,683 all-comers patients from the DISTRACTION registry.

Background: Distal transradial access (dTRA) as an improvement of the traditional transradial approach has several potential advantages including operator and patient comfort, faster hemostasis, and lower risk of proximal radial artery occlusion (RAO). We aim to describe our real-world experience with dTRA as default approach for routine coronary angiography and percutaneous coronary interventions (PCI) in a broad and prospective cohort of all-comers patients. Methods: In the DISTRACTION registry, a total of 3,683 consecutive all-comers patients who underwent coronary procedures via dTRA were included. Results: The mean patient age was 63.3±13.5-year-old, 66.1% were male, 39.7% had diabetes, and 50.2% presented with acute coronary syndromes (ACS). Overall, 20% of patients had non-ST-elevation myocardial infarction (NSTEMI), 22.9% had ST-elevation myocardial infarction (STEMI), and 2.6% presented in cardiogenic shock. There were 2.5% access site crossovers, 16% of those were performed via contralateral dTRA; thus, in only 77 (2.1%) patients dTRA sheath insertion could not be obtained. Right dTRA (rdTRA) was the most frequent access (80.2%), followed by redo ipsilateral dTRA (10.5%), left dTRA (ldTRA) (8.6%) and simultaneous bilateral dTRA (0.7%). PCI was performed in 60.4% of all cases, and left anterior descending was the most treated vessel (29%). No access site-related hematoma type ≥2, according to EASY classification was recorded. No hand/thumb dysfunction after any procedure was documented. One patient developed a pseudoaneurysm, and one had guidewire-induced forearm radial artery perforation. There were neither major complications nor major adverse cerebrovascular and cardiac events directly related to dTRA. Conclusions: In this large, prospective, all-commers patients registry the adoption of dTRA as standard for routine coronary interventions appears to be safe and feasible.

Unprotected Left Main Primary PCI via Distal Transradial Access in the Setting of STEMI-Related Cardiogenic Shock.

Despite all well-known benefits of transradial access, patients presenting with cardiogenic shock are usually submitted to coronary angiography and percutaneous coronary intervention via traditional transfemoral access, mainly due to challenge puncture of radial artery in the setting of hemodynamic instability. We report a challenging case of STEMI-related cardiogenic shock requiring primary PCI of an occluded and unprotected left main, safety, and successfully performed via right distal trans radial access in the anatomical snuffbox.

Chronic Total Occlusion Recanalization Concurrent to Culprit Primary Percutaneous Coronary Intervention via Distal Transradial Access: Maximizing Revascularization Through Minimalist Approach.

For ST-segment elevation myocardial infarction (STEMI) patients with multi-vessel coronary disease, complete revascularization is superior to culprit-only percutaneous coronary intervention (PCI). Chronic total occlusion represents the most challenging setting for PCI. Distal transradial access (dTRA) has advantages such as faster hemostasis and risk of proximal radial artery occlusion. We report a case of nonculprit coronary total occlusion recanalization concurrent to culprit primary PCI via dTRA in the setting of STEMI.

Distal transradial access as default approach for coronary angiography and interventions.

BACKGROUND: Distal transradial access (dTRA) as a refinement of the conventional transradial access has advantages in terms of patient and operator comfort and risk of radial artery (RA) occlusion. RA preservation with this new technique could be a relevant issue in patients requiring its future use. In turn, one relevant drawback is the more challenging puncture of a smaller artery. In order to evaluate the real world feasibility and safety of both right (rdTRA) and left (ldTRA) distal transradial access as default access site for routine coronary angiography (CAG) and percutaneous coronary intervention (PCI), this prospective observational registry was conducted. METHODS: From February to July 2019, 435 consecutive patients underwent CAG and/or PCI (620 procedures at all, by two experienced transradial operators) through rdTRA or ldTRA. RESULTS: Mean patient age was 62.4 years old. Most were male (66.0%). The majority (49.4%) of patients had an acute coronary syndrome; overall, 15.2% with ST-elevation acute myocardial infarction (STEMI). Distal RA was successfully punctured in all patients, always without ultrasound guidance, with puncture and sheath insertion at until 2 attempts in the vast majority of patients. We had only 3.0% access site crossovers (successful arterial puncture but failed sheath insertion), mainly performed via the contralateral dTRA (53.8%). Successful dTRA sheath insertion was then achieved in 98.6% of all 435 patients. Redo ipsilateral dTRA was performed in 2.5% of patients. Distal and proximal RA pulses were palpable in all patients at hospital discharge. No major adverse cardiac and cerebrovascular events and no major complications were recorded. CONCLUSIONS: dTRA as default approach for routine CAG and/or PCI by experienced transradial operators appears to be safe and feasible. Further randomized and larger trials are still needed to assure the clinical benefits and the safety of this new technique.