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Ultrasound-Guided Access of the Distal Radial Artery at the Anatomical Snuffbox for Catheter-Based Vascular Interventions: a Technical Guide

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Ultrasound-Guided Access of the Distal Radial Artery at the Anatomical Snuffbox for Catheter-Based Vascular Interventions: a Technical Guide Title: Ultrasound-guided access of the distal radial artery at the anatomical snuffbox for catheter-based vascular interventions: A technical guide. Authors: Anastasia Hadjivassiliou, MBBS, BSc; Ferdinand Kiemeneij, M.D, PhD; Sandeep Nathan, M.D, MSc; Darren Klass, M.D, PhD DOI: 10.4244/EIJ-D-19-00555 Citation: Hadjivassiliou A, Kiemeneij F, Nathan S, Klass D. Ultrasound-guided access of the distal radial artery at the anatomical snuffbox for catheter-based vascular interventions: A technical guide. EuroIntervention 2019; Jaa-625 2019, doi: 10.4244/EIJ-D-19-00555 Manuscript submission date: 10 June 2019 Revisions received: 24 July 2019 Accepted date: 01 August 2019 Online publication date: 06 August 2019 Disclaimer: This is a PDF file of a "Just accepted article". This PDF has been published online early without copy editing/typesetting as a service to the Journal's readership (having early access to this data). Copy editing/typesetting will commence shortly. Unforeseen errors may arise during the proofing process and as such Europa Digital & Publishing exercise their legal rights concerning these potential circumstances. Ultrasound-guided access of the distal radial artery at the anatomical snuffbox for catheter-based vascular interventions: A technical guide Anastasia Hadjivassiliou, MBBS, BSc1; Ferdinand Kiemeneij, MD, PhD2; Sandeep Nathan, MD, MSc3; Darren Klass, MD, PhD1 1. Department of Interventional Radiology, Vancouver General Hospital, University of British Columbia, Canada 2. Department of Cardiology, Tergooi Hospital, Blaricum, the Netherlands 3. University of Chicago Medicine, Chicago, IL, USA Short title: Ultrasound guided distal radial artery access at the anatomical snuffbox Corresponding author: Dr Darren Klass Department of Radiology, Vancouver General Hospital 899 West 12th Avenue, V5Z 1M9, Vancouver, BC, Canada Email address: [email protected] Disclaimer : As a public service to our readership, this article -- peer reviewed by the Editors of EuroIntervention - has been published immediately upon acceptance as it was received. The content of this article is the sole responsibility of the authors, and not that of the journal Conflicts of interest: Dr Anastasia Hadjivassiliou: None Dr Sandeep Nathan: Consultant for Medtronic Inc, Merit Medical and Terumo Interventional systems Dr Ferdinand Kiemeneij: Consultant for Merit Medical Dr Darren Klass: Consultant for Merit Medical Disclaimer : As a public service to our readership, this article -- peer reviewed by the Editors of EuroIntervention - has been published immediately upon acceptance as it was received. The content of this article is the sole responsibility of the authors, and not that of the journal Classifications: Radial Abstract: Conventional radial access has been shown to have many advantages over transfemoral approach. The risk of potential radial artery occlusion and subsequent hand ischaemia can be reduced further by accessing the vessel distally at the anatomical snuffbox, allowing for maintenance of antegrade flow to the hand by the superficial palmar arch branch. Additional potential advantages of distal radial access in comparison to the conventional radial approach at the wrist include fewer puncture site complications and faster post-procedural haemostasis as the vessel is very superficial. Furthermore, it provides another safe, non-femoral option for vascular access. The use of ultrasound guidance enables the operator to identify important anatomical landmarks and avoid injuring adjacent structures. We provide a detailed step-by-step guide for performing distal radial access using sonographic and anatomical correlation thereby facilitating safe access and optimising technical success. Abbreviations: US: Ultrasound Disclaimer : As a public service to our readership, this article -- peer reviewed by the Editors of EuroIntervention - has been published immediately upon acceptance as it was received. The content of this article is the sole responsibility of the authors, and not that of the journal Introduction: Transradial coronary stent placement was first described in 1993 (1), with its advantages over femoral access being well documented since (2, 3, 4). Distal radial access at the anatomical snuffbox has been utilised in Iran and Russia, but no publications existed in Western literature until recently (5). The concept was introduced in Russia by Dr Babunashvili to facilitate retrograde radial artery recanalisation. This was followed by Dr Kaledin’s experience in over 2500 patients which was presented in Cardio Update Europe in 2017. Dr Roghani shared his experience in 2016, utilising the technique in female patients who wear bracelets covering the forearm, limiting haemostasis. Since 2016, the global adoption of distal radial technique has increased significantly in interventional cardiology, radiology and neurology (6-8). The risk of symptomatic hand ischemia is low following conventional radial access, however this risk can potentially be reduced further, by using the distal radial artery for access as the vessel is punctured distal to the origin of the superficial palmar arch branch (Central Illustration). If radial occlusion occurs, the arch branch will remain patent and therefore preserve continuous antegrade flow to the hand. The length of occluded vessel should thus be limited to the segment between the access site and the origin of the superficial palmar arch. In comparison to conventional radial access, the distal radial artery is more superficial which lends itself to even faster post-procedural haemostasis. Furthermore, the location of the puncture site allows movement at the wrist during recovery, which is otherwise limited with the conventional approach. A small study has shown that the size of the distal radial artery at the anatomical snuffbox is not significantly different than at the wrist. This is also reflected in the comparably high technical success rates (9). With no significant calibre change, sheath downsizing is unnecessary when accessing the vessel distally. The anatomical snuffbox Disclaimer : As a public service to our readership, this article -- peer reviewed by the Editors of EuroIntervention - has been published immediately upon acceptance as it was received. The content of this article is the sole responsibility of the authors, and not that of the journal is defined as the triangular depression in the dorsum of the hand at the base of the thumb; it is bordered by the abductor pollicis longus and extensor pollicis brevis laterally and the extensor pollicis longus medially. The floor is comprised of the scaphoid and trapezium carpal bones. The contents of the anatomical snuffbox include the distal radial artery, cephalic vein and superficial branches of the radial nerve; care should therefore be taken when obtaining access. This is particularly important when only palpation, rather than ultrasound (US) guidance, is used for access. A blind puncture increases the risk of inadvertent tendon damage, while the double wall technique can cause irritation of the underlying periosteum. Double wall puncture could increase the risk of hematoma formation, caused by leakage of blood through the punctured back wall of the distal radial artery. Furthermore, if the vessel is accessed distal to the snuffbox (i.e. within the first web space), the haematoma risk increases, as there are no bones to provide support during haemostasis. In addition, a puncture distal to the extensor pollicis tendon may result in inadvertent access of the wire in a branch of the deep palmar arch. The radial pulsation may be more prominent in the latter region rather than in the snuffbox and may thus mislead the inexperienced operator. The utilisation of US allows identification of anatomical landmarks and enables accurate vessel access. The probe can be used to perform a compressibility test to confirm that the target vessel corresponds to the radial artery rather than the cephalic vein; the artery will appear pulsatile and will not collapse once pressure is applied, whereas on the contrary the vein will be readily compressible. Meticulous scanning can identify the superficial branch of the radial nerve thus avoiding potential injury; the cutaneous branch nerve is located superficially in the snuffbox. A further benefit of US guidance is that the operator can measure the vessel size prior to puncturing, in order to determine whether it can accommodate the required procedural sheath and hardware. The purpose Disclaimer : As a public service to our readership, this article -- peer reviewed by the Editors of EuroIntervention - has been published immediately upon acceptance as it was received. The content of this article is the sole responsibility of the authors, and not that of the journal of this article is to provide a detailed step-by-step technical approach for performing US guided access of the distal radial artery and discuss technical considerations specific to image guided vascular access. Patient selection: Patient selection is crucial prior to embarking on radial access. Historically, the Barbeau test was recommended (10), however it has been shown to be a variable predictor for the risk of hand ischaemia (11). Palpation of the radial pulse can be unreliably weak in patients with systemic shock or underlying vascular disease. Alternatively the pulse can falsely present distally in patients with proximal radial occlusions, as a result of robust palmar collaterals. Significant benefits of US in such patient populations therefore include
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