Conventional transradial access (TRA) is already established as the access of choice for percutaneous coronary procedures, regardless of clinical presentation.
This choice is based on multiple randomized studies and meta-analyses that have shown reduced bleeding at the puncture site, less vascular complications, and benefits on mortality (mainly in high-risk patients). The practicality of recovery allows for earlier hospital discharge and, in turn, diminished health costs.
Radial artery occlusion (RAO) is the most frequent complication driven by many triggering factors. It has a higher incidence within the first 24 hours, while spontaneous rechanneling after 30 days has been observed in 50% of patients.
In recent years, using distal radial access (DRA)—considered as a great alternative— has increased as the location of the puncture site in relation to the anastomotic network of the hand entails a lower risk for RAO.
The aim of this study was to evaluate the efficacy and safety of DRA compared with the conventional transradial approach, having implemented a systematic approach to prevent RAO.
Read also: Transfemoral vs Transradial Approach in the Percutaneous Treatment of CTO.
This study, called DISCO RADIAL, was presented simultaneously in JACC and EuroPCR 2022. It is a randomized, prospective, multicenter, open international study. Patients who underwent placement of a Glidesheath Slender 6F introducer were randomized 1:1 to DRA or TRA. Patients with ST-segment elevation acute coronary syndrome or undergoing angioplasty for chronic total occlusion were excluded. Recommendations included the administration of verapamil 5 mg and/or nitroglycerin 100 to 200 mcg, followed by heparin 5000 IU and corrections to achieve an activated clotting time of 250-300 seconds.
The primary endpoint (PEP) was the incidence of RAO at hospital discharge via doppler measurement. Secondary endpoints (SEPs) were successful introducer insertion, puncture site crossover, introducer insertion time, procedure time, puncture site bleeding, or access complications.
A total of 1307 patients were included; their mean age was 68 years, 30% had diabetes, 33.8% had undergone previous angioplasty via transradial approach, and the main indication for intervention was chronic coronary syndrome (84.9%).
There was a non-significant decrease in the PEP (0.91% vs. 0.31%; p = 0.29). Analyzing the population by protocol (crossover 7.4% in DRA) showed the same results (0.81% vs. 0.34%; p = 0.45). When analyzing the SEPs, the DRA group had higher rates of spasm (2.7% vs. 5.4%; p = 0.015) and shorter time to achieve hemostasis (180 min vs. 153 min; p = 0.0001), without showing significant differences in bleeding and vascular complications.
Conclusions
This study showed a much lower rate of RAO than prior meta-analyses (0.81% vs. 7.7%). This means that systematically taking measures to prevent RAO was effective for both accesses, yielding a non-significant decrease between them. As this is currently the study with the largest population, based on these data, TRA should remain the gold standard.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Distal Versus Conventional Radial Access for Coronary Angiography and Intervention (DISCO RADIAL).
Source: Aminian, Adel et al. “Distal Versus Conventional Radial Access for Coronary Angiography and Intervention (DISCO RADIAL).” JACC. Cardiovascular interventions, S1936-8798(22)00897-4. 10 May. 2022, doi:10.1016/j.jcin.2022.04.032
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