Uses of Distal Radial Access: Are We There Yet?

KARIM AL-AZIZI, MD, FACC, FSCAI INTERVENTIONAL CARDIOLOGY AND STRUCTURAL HEART DISEASE, ASSOCIATE THE HEART HOSPITAL BAYLOR PLANO Disclosures

Consultant, Edwards Lifesciences Consultant, Volcano

2 Background • Despite the emergence of radial artery catherization, femoral access remains the most common route for patients undergoing procedures in the US.

• Conventionally, the right radial access has been the “go to access” when the radial artery is chosen as an access vessel.

• Left radial artery is reserved for patients with bypass grafts or weak un accessible right radial, and bad femoral access points.

• Left radial has been criticized for bad operator ergonomics and lack of patient’s comfort during the procedure due to a supinated hand. Radial vs Femoral

Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet 2011;377:1409-20. Radial vs Femoral

5 Radial vs Femoral

JACC Cardiovasc Interv. 2016 Jul 25;9(14):1419-34. doi: 10.1016/j.jcin.2016.04.014. Epub 2016 Jun 29. Radial Versus Femoral Access for Coronary Interventions Across the Entire Spectrum of Patients With Coronary Artery Disease: A Meta-Analysis of Randomized Trials.

Radial vs Femoral Disadvantages of the radial access

– Small caliber of the artery

– Radial artery spasm, radial loops and subclavian stenosis/tortuosity may limit the ability to manipulate catheters and can be very painful.

– The fluoroscopy time and radiation may be increased.

– 10% crossover rate. The Radial vs Femoral argument

2019 2020 Why distal radial artery? Anatomy of the ”snuff box” Advantages

Courtesy of Prof. Kiemeneij Why distal left radial

– Better patient and operator ergonomics

– Easier and more predictable hemostasis with the radial artery compression over the scaphoid bone, with shorter hemostasis times → better patient satisfaction

– Preserve the proximal left radial and right radial for future procedures, AV fistula, radial grafts for surgery etc...

– Ability to flex the wrist, and ability to use the right hand after the procedure with no risk of hematoma. Disadvantages • Not a “one size fits all”…..radial artery size, hand size.

• Patients with large abdominal girth or severe left shoulder arthritis, may not be good candidates for this access.

• Not an ideal access for an unstable patient.

• Requires radial artery access skillset and experience.

• Tortuous course of the radial artery may be challenging.

• More data…more data … more data NEEDED! Door to balloon to phone time!

Courtesy of Dr. Kim Technique and Closure Access

Hemostasis

EuroIntervention. 2017 Sep 20;13(7):851-857. doi: 10.4244/EIJ-D-17-00079. Left distal transradial access in the anatomical snuffbox for coronary angiography (ldTRA) and interventions (ldTRI).

The distal left radial artery for coronary angiography and intervention: A US experience Karim Al-Azizi, MD1, Kyle Gobeil, DO2, Vikram Grewal, MD2, Khawar Maqsood, MD2, Ali Haider, MD2, Amir Mohani, MD2, Gregory Giugliano, MD2, Amir Lotfi, MD2 1 The Heart Hospital, Plano – Baylor Scott & White, 2 Baystate Medical Center – University of Massachusetts Medical School

lDTRA Results: Procedure related data (n=61) dLTRA was attempted in 61 patients. Access was Background: Indication for cardiac catheterization successful in 60 patients (98.4%) with one patient The radial artery is the access of choice in many Unstable angina 18 (29.5) failed cannulation of distal left radial. Conversion catheterization labs around the world due to its proven NSTEMI 26 (42.6) occurred in 1 patient (1.7%), requiring an additional benefits over the femoral artery access. Though the right STEMI 1 (1.6) arterial access to complete the coronary radial artery is the preferred side, there has been growing Non ACS 16 (26.2) angiography. 34 patients (55.7%) required interest in utilizing the left radial especially in patients with Sheath size percutaneous coronary intervention (PCI).There bypass grafts. It has been widely criticized due to the lack 5 8 (13.1) were no access site bleeds post procedure, no of good ergonomics and patient comfort during the 6 53 (86.9) hematomas, with 100% successful hemostasis with procedure. The distal left radial artery access (dltra) has Diagnostic catheters per case (mean) 2.09 a radial band. There were 2 cases requiring re- helped resolve these issues. We sought to evaluate the Guiding catheters per case (mean) 1.1 access of the distal left radial artery access for feasibility, safety and complication rates of the distal left FFR 12 (19.7) repeat revascularization, with procedure success radial artery access for coronary angiography and PCI 34 (55.7) and good left radial artery patency intervention. IVUS 6 (9.8) Coronary artery treated Left Main 1 (1.6) Conclusion: Left Anterior Descending Artery 12 (19.7) dLTRA is a safe and feasible arterial access in a Left Circumflex 10 (16.4) radial experienced catheterization lab. dLTRA Right Coronary Artery 16 (26.2) provides improved operator ergonomics and Methods: Mean contrast volume (cc) 126.7 patient’s comfort, in addition to the advantage of This is a single arm cohort evaluating patients who 4.32 able to cannulate the bypass grafts and with underwent dlTRA attempt. Patients were consented Mean Lido stick to sheath time minutes very low risk of vascular complications. for a cardiac catheterization with possible coronary Mean Flouro time (hh:mm:ss) 0:18:18 intervention. The distal left radial artery is accessed Mean Procedure time (hh:mm) 1:34 in the anatomical snuff box, and the sheath is inserted carefully. The procedure was completed References using standard diagnostic and guiding catheters. Hemostasis was achieved with a radial band. Outcomes 1. Kiemeneij F, Laarman GJ (1993) Percutaneous trans-radial artery approach for coronary stent implantation. Cathet Cardiovasc Procedure success was defined as ability to Successful completion of the 59/61 Diagn. 30: 173-8. complete the procedure without conversion to a cardiac catheterization (96.7%) 2. Kiemeneij F, Laarman GJ, Odekerken D (1997) A randomized comparison of percutaneous transluminal coronary angioplasty by different access site due to failure of coronary artery Successful cannulation and the radial, brachial and femoral approaches: the access study. J cannulation. We evaluated the rates of procedure insertion of the sheath through the 60/61 Am Coll Cardiol. 29: 1269-75. 3. Kiemeneij F (2017) Left distal transradial access in the anatomical success, complication rates and failure of distal left radial artery (98.4%) snuffbox for coronary angiography (ldTRA) and interventions hemostasis. Conversion rate 1/60 (1.7) (ldTRI). EuroIntervention. 13: 851-857. 4. Al-Azizi KM, Lotfi AS. (2018) The distal left radial artery access for Major bleeding 0 coronary angiography and intervention: A new era. Cardiovasc Post-procedure radial band Revasc Med. 2018 Mar 26. pii:S1553-8389(18)30123-4.doi: 10.1016/j.carrev.2018.03.020. hematoma 0 5. Davies RE, Gilchrist IC. Back hand approach to radial access: the snuff box

Cardiovasc Revasc Med. 2019 Sep;20(9):786-789. doi: 10.1016/j.carrev.2018.10.023. Epub 2018 Oct 25. 6,746 patients (dTRA, n = 3,209; cTRA, n = 3,537)

The failure rate was similar in the dTRA and cTRA groups (RR: 1.36; 95% confidence interval [CI]: 0.41 to 4.48; p = 0.62).

No difference was observed between dTRA and cTRA with regard to access-site hematoma (RR: 1.01; 95% CI: 0.49 to 2.07; p = 0.99), radial artery spasm (RR: 0.91; 95% CI: 0.32 to 2.62; p = 0.86), or radial artery dissection (RR: 0.63; 95% CI: 0.18 to 2.16; p = 0.46). Presented at TCT 2019

300 Patients

1:1 Randomization

150 Patients, US guided 150 Patients, US guided access PROXIMAL Radial access DISTAL Radial

30 days 30 days HAND FUNCTION HAND FUNCTION RAO EVALUATION RAO EVALUATION

1 year 1 year HAND FUNCTION HAND FUNCTION RAO EVALUATION RAO EVALUATION

Conclusion

• Distal radial artery access for coronary angiography and interventions is feasible in patients that are carefully selected and are deemed good candidates.

• May have further advantages over the traditional right radial access,

• lower RAO??

• There is a learning curve for developing such program, as is the case with conventional radial access.

• More studies are needed to understand the impact of such alternative upper extremity arterial access on patient’s outcomes.

Thank you!