The feasibility and safety of distal transradial access (dTRA) for coronary angiography (CAG) or percutaneous coronary intervention (PCI) has been reported recently, and it is expected that dTRA is going to be popular worldwide [
This study recruited the patients who underwent CAG or PCI with dTRA between September 2018 and February 2019 at the Saiseikai Kanagawa Prefecture Hospital. Specifically, conventional dTRA was performed between September 2018 and November 2018, and ultrasound-guided dTRA was performed between December 2018 and February 2019. Of the 247 eligible patients (298 procedures), 166 consecutive patients (185 procedures) were assigned to the experienced interventional cardiologist (Dr. SM) operation program. In total, 137 patients (144 procedures) were considered suitable to undergo dTRA for CAG or PCI and further analyzed in this study. These patients were classified into two groups: C (dTRA with conventional punctures; 76 patients, 79 procedures) and U (dTRA with ultrasound-guided punctures; 61 patients, 65 procedures) groups. The remaining 29 patients did not undergo dTRA due to various reasons: the absence of a pulse in the distal radial artery (
Study flowchart. CAG: coronary angiography; PCI: percutaneous coronary intervention.
The region around the anatomical snuffbox was prepped and covered with a sterile material, and local anesthesia around the puncture site was administered with 5.0 mL of 1.0% lidocaine. The distal radial artery was punctured by the conventional method, and a 20-gauge (G) puncture needle was used in the same manner as that of a transradial access. The ultrasound-guided puncture was performed with a 20 G needle under the long-axis ultrasound guidance (Figures
(a) A puncture with a 20 G needle under the long-axis ultrasound guidance. (b) The way of using the patient’s hand that has a wineglass makes us puncture under ultrasound guidance easily. (c) Long-axis ultrasound shows the distal radial artery. (d) The Doppler-ultrasound shows the blood flow in the radial artery. (e) Ultrasound shows the puncture with a 20 G needle.
Procedural failure implied switching to another puncture site. When a conventional dTRA was performed, any requirements to switch to ultrasound-guided dTRA were regarded as a procedural failure. The puncture was defined as the duration between draping with a sterile material to sheath insertion, while the procedural time was defined as the duration between the sheath insertion and sheath removal. Complications included access-site ecchymosis, major or minor hemorrhage, nerve disorder, and the occurrence of RAO. Minor and major bleeding implied Bleeding Academic Research Consortium (BARC) type 1 or 2 and type 3 or 5 bleeding, respectively [
All statistical analyses were performed by the JMP software (version 13, SAS Institute, Cary, NC, USA). Categorical variables are expressed as frequencies, while continuous variables with normal distribution are expressed as mean ± standard deviation. Categorical variables were compared with the chi-square test or Fisher exact test, while continuous variables were compared with the unpaired Student’s
In this study, 137 patients (144 procedures) were investigated. Patients and procedural characteristics are shown in Table
Patient and procedural characteristics.
U group (61 patients, 65 procedures) | C group (76 patients, 79 procedures) | ||
---|---|---|---|
Age, years | 70.4 ± 10.5 | 74.1 ± 9.6 | 0.03 |
Male, % | 42 (69) | 53 (70) | 0.91 |
Height, cm | 161.4 ± 10.4 | 162.1 ± 9.0 | 0.67 |
Weight, kg | 64.6 ± 16.1 | 62.0 ± 11.3 | 0.27 |
BMI, kg/m2 | 25.0 ± 4.0 | 23.8 ± 3.5 | 0.08 |
Smoking, % | 14 (23) | 19 (25) | 0.86 |
Hypertension, % | 48 (79) | 60 (79) | 0.97 |
Diabetes mellitus, % | 30 (49) | 29 (38) | 0.20 |
Dyslipidemia, % | 45 (74) | 52 (68) | 0.49 |
eGFR, ml/min/1.73 m2 | 62.8 ± 26.6 | 60.9 ± 21.6 | 0.65 |
CKD, % | 22 (36) | 29 (38) | 0.80 |
Hemodialysis, % | 6 (10) | 4 (5) | 0.31 |
PAD, % | 5 (8) | 4 (5) | 0.49 |
CVD, % | 4 (7) | 4 (5) | 0.75 |
Prior MI, % | 6 (10) | 6 (8) | 0.69 |
Aspirin, % | 53 (87) | 62 (82) | 0.40 |
Thienopyridine, % | 42 (69) | 55 (72) | 0.65 |
Anticoagulant, % | 5 (8) | 7 (9) | 0.83 |
Left hand, % | 17 (27) | 23 (29) | 0.60 |
Sheath size | |||
4 Fr, % | 0 | 2 (3) | 0.32 |
5 Fr, % | 57 (88) | 64 (81) | |
6 Fr, % | 8 (12) | 13 (16) | |
CAG, % | 45 (69) | 55 (70) | 0.96 |
PCI, % | 20 (31) | 24 (30) |
BMI, body mass index; CKD, chronic kidney disease; PAD, peripheral artery disease; CVD, cerebral vascular disease; MI, myocardial infarction; CAG, coronary angiography; PCI, percutaneous coronary intervention; eGFR, estimated glomerular filtration rate.
The procedural success rate was significantly higher in the U group than in the C group (97% vs. 87%,
The success rate of puncture.
Procedural outcomes. (a) Puncture time. (b) Procedural time. (c) Contrast volume. (d) Radiation dose. (e) Radiation time.
Complication rate. RAO: radial artery occlusion. (a) Access-site ecchymosis. (b) Minor bleeding. (c) Major bleeding. (d) Nerve disorder. (e) RAO.
In total, 7 cases were switched from conventional puncture to ultrasound-guided puncture, and procedures in all these cases were completed via ultrasound-guided dTRA. A representative case is described in the following. One patient had a chest pain due to a left anterior descending stenosis that was detected by coronary computed tomography angiography. The pulse of the bilateral distal radial artery was weak since the patient underwent CAG or PCI multiple times. Initially, a conventional puncture was attempted but it failed. Therefore, we switched to ultrasound-guided dTRA. The Doppler-ultrasound revealed the blood flow in the left distal radial artery, and thus, it was easy to puncture the distal radial artery under ultrasound guidance. Angiography after puncture revealed RAO (Figure
(a) Angiography from the distal radial artery shows the total occlusion of the radial artery (arrow). (b) Guidewire advance into the brachial artery. (c) After an exchange to 0.014-inch guidewire, balloon dilatation is performed. (d) Angiography from the distal radial artery shows the patency of the radial artery after the procedure.
This study is, to the best of our knowledge, the first report on the comparison between ultrasound-guided and conventional dTRA for CAG or PCI. This study demonstrated that ultrasound-guided dTRA for CAG or PCI can improve the rate of successful puncture, even though there were no significant differences in procedural outcomes and complication rates.
TRA for coronary diagnosis or revascularization procedure is progressively used worldwide since it is associated with lower bleeding and vascular complications than trans-femoral access [
Another potential advantage of ultrasound-guided dTRA is that it enabled us to puncture the distal radial artery even when the distal radial artery is not suitable for the conventional dTRA procedure. In the present study, switching to ultrasound-guided puncture from conventional puncture was required in 7 cases, and procedures in all these cases were completed via ultrasound-guided dTRA. The pulse of the distal radial artery can become weak after attempts of unsuccessful conventional puncture, because hematoma or vessel spasm can occur. In such situations, we could puncture the distal radial artery as far as the blood flow is visible with the Doppler-ultrasound.
As such, if an ultrasound machine is available in a catheterization laboratory, ultrasound-guided dTRA is preferred.
This study has a few limitations. It is a single-center study and a single operator performed both conventional and ultrasound-guided dTRA. In addition, grouping according to the time period may have potentially led to bias. Moreover, the study was conducted on a small sample, and thus, further large-scale studies are needed to validate the findings of this study.
The ultrasound-guided dTRA for CAG or PCI was associated with a lower failure rate than conventional dTRA. However, there were no significant differences in puncture time and complication rate between the two procedures.
No data were used to support this study.
The authors declare no conflicts of interest.
The authors would like to thank Mr. Masaru Tamura for data collection at the Saiseikai Kanagawa Prefecture Hospital.