Left Distal Radial Artery Access for Coronary Angiography and Interventions: A 12-Month All-Comers Study

Abstract

Background. Interventional cardiologists prefer the right radial artery (RA) approach for coronary angiography and interventions, mainly for ergonomic reasons. However, the use of the left RA presents certain advantages, and the snuffbox approach has further potential advantages, including lower probability for RA occlusion, avoidance of direct puncture of the RA (thus maintaining its suitability for use as a graft), as well as easier and faster hemostasis. Methods. Consecutive patients scheduled for coronary catheterization were included, using the left distal RA (ldRA) in the anatomical snuffbox as the default vascular access site. Results. Out of 2034 consecutive cases, the ldRA was used as initial vascular access in 1977 patients (97.2%). The procedural failure rate was 9.9% (21.9% inability to puncture the artery, 75.0% inability to advance the wire, 3.1% other reasons). There was a sharp decrease in failure rate after about the first 200 cases (20.8% in the first decile vs 8.7% throughout the rest of the caseload; P<.001). No or very weak palpable pulse was the most important predictor of failure (odds ratio, 16.0; 95% confidence interval, 11.2-23.1; P<.001), in addition to older age, small stature, and female gender (although, after adjustment for height, the latter was no longer significant). Conclusion. In a large series of consecutive patients scheduled for left heart catheterization, through a period of 12 months, with virtually no exclusions except those few imposed by anatomy or compelling clinical needs, the ldRA arterial access approach was shown to be highly effective, feasible, and safe.

Keywords: anatomical snuffbox, transradial, vascular access

Transradial artery access has become the default arterial access approach for coronary catheterization in most laboratories due to a number of advantages over the femoral approach, including faster patient mobilization, reduced patient discomfort, and lower incidence of bleeding complications.¹ Right transradial access has become a mainstay, mainly due to ergonomic reasons, considering that the left radial artery approach may be cumbersome, especially in obese patients and for operators of short stature, with special care needed to maintain the patient’s left hand in a supine and over-extended position over the patient’s abdomen, which may be a cause for additional patient discomfort. The left transradial approach, on the other hand, presents certain procedural advantages, including less acute curvatures² (especially at the subclavian artery-aortic junction level), immediate use of the right hand in right-handed patients, representing the vast majority of catheterized patients, and easy access to the left internal mammary artery ostium when necessary (ie, in patients with a history of coronary bypass surgery). The left distal radial artery (ldRA) approach, in the anatomical snuffbox area, offers an alternative puncture site that may be an advantageous first-line option for vascular access.³ Published evidence in this topic is limited.

The aim of the present study was to test the effectiveness, safety, and feasibility of the routine use of the ldRA approach (punctured in the anatomical snuffbox area) as default arterial access for coronary angiography and percutaneous coronary interventions on an all-comer basis over a 12-month interval in a tertiary hospital catheterization laboratory.

Methods

Study population and design. This was an observational study, conducted over a period of 12 months (December 24, 2018 to December 23, 2019), including consecutive procedures of coronary angiography and/or percutaneous coronary intervention, where the ldRA in the anatomical snuffbox was used as the default vascular access site. Only patients with anatomical or other conditions precluding the use of the left radial artery (eg, previous harvesting of the left radial artery for coronary bypass, etc) were excluded. Left-handed patients were catheterized through the right distal radial artery and were not included in the present analysis. No other exclusion criteria were applied. Patient demographics, epidemiologic data, and somatometric data were recorded. Body surface area was calculated with the DuBois formula (0.007184 × weight^0.425 × height^0.725). The study was approved by the institutional review board.

Procedural details. The left hand was disinfected in the wrist and snuffbox area and placed over the abdomen, with the elbow supported by a pillow. The wrist was placed in a vertical position ready for local anesthesia, puncture, and cannulation, and was turned into a pronated position for performance of the procedure. The ldRA (Figure 1) was palpated by the operator and the level of palpability was graded on a 4-grade scale (not palpable, just palpable, well palpable, very well palpable). The anatomical snuffbox was infiltrated with lidocaine solution 2% using a 25-G insulin needle. A quantity of 1-2 mL was used, with special attention paid not to infuse in the artery and avoid swelling of the small snuffbox fossa, which may cause weakness or even loss of palpability of the ldRA, making artery puncture difficult or even impossible. Infiltration of snuffbox-orienting tendons should be avoided, since this might cause aseptic tenosynovitis. The PreludeEase hydrophilic sheath introducer set (Merit Medical) was used in all cases. After placement of the sheath, heparin 5000 units and glyceryl trinitrate 0.2 mg were administered intra-arterially.

The primary outcome measure was vascular-access-related procedural failure, defined as failure to gain access through the ldRA (inability to puncture or to advance a wire) leading to transition to a different arterial access site. Secondary outcomes were patient-reported postprocedural pain or numbness of the left hand and/or forearm, any vascular complications in the left upper limb, and postprocedural radial artery occlusion. Vascular ultrasound was performed in all cases of any access-site-related symptom reported by the patient.

Statistical analysis. Continuous variables were summarized as median with interquartile range (IQR) and compared with nonparametric tests (Mann-Whitney). Categorical variables were summarized as counts and percentages and compared with the Chi-square test. Mantel-Haenszel odds ratios were calculated to evaluate and compare the likelihood of vascular access failure between different patient subgroups. Univariate correlations with vascular access failure were adjusted for potential confounders using binary logistic regression as needed. SPSS statistics, version 25.0 (IBM) was used for statistical analysis.

Results

Out of 2034 consecutive cases (patients slated for coronary angiography and/or percutaneous coronary intervention), the ldRA was used as initial vascular access site in 1977 cases (71.8% male, median patient age 66 years (IQR, 58-74), 28.3% diabetics, and 69.2% history of hypertension). In 42 cases, the patients were left handed (the right distal radial artery was used in these patients) and 15 were excluded due to anatomical or other reasons that rendered the use of the left radial artery impossible or unfeasible (eg, prior harvesting of the left radial artery for coronary bypass, presence of orthopedic casts due to bone fracture, presence of arteriovenous fistula for hemodialysis, amputated left upper limb). In 167 cases (8.4%), the ldRA had been punctured and catheterized at least once in the past. Sheath sizes used were 4 Fr (2 cases; 0.1%), 5 Fr (1385 cases; 70.1%), 6 Fr (579 cases; 29.3%), and 7 Fr (11 cases; 0.6%).

Ad hoc percutaneous coronary interventions were performed in 365 cases (18.5%), 86 of which were primary interventions in patients with ST-segment-elevation myocardial infarction. Of the remaining 1612 cases, 1443 were coronary angiographies and 169 were elective percutaneous coronary interventions. Additional diagnostic and interventional techniques were employed as needed, including, for example, rotational atherectomy (utilizing up to 7-Fr sheaths), which was performed in 14 cases.

The overall vascular-access-related procedural failure rate was 9.9% (196 cases); 21.9% of these (43 cases) were due to inability to puncture the artery in the anatomical snuffbox, 75.0% were due to inability to advance the wire (147 cases), and 3.1% (6 cases) were due to other reasons (eg, obstruction at the level of the subclavian, dissection of the radial artery, etc). There was a discernible learning curve, as indicated by the decrease in failure rate from approximately 20% in the first 200 cases to less than 10% in the next 200 cases (20.8% in the first decile vs 8.7% throughout the rest of the caseload; P<.001) (Figure 2).

Age was positively associated with procedural failure (69 years [IQR, 60-76] in cases with failure vs 66 years [IQR, 58-74] in cases without failure; P=.03). Small stature was a powerful univariate correlate of procedural failure in terms of weight, height, and body surface area (Figure 3). In patients with height greater than the median, procedural failure was 53.3% less likely (95% confidence interval [CI], 35.6-66.1; P<.001) compared with patients with height lower than the median. The corresponding figures for body weight and body surface area were 28.1% (95% CI, 3.1-46.6; P=.03) and 39.2% (95% CI, 17.7-55.0; P<.01), respectively. Women were 75.2% more likely to have vascular-access-related procedural failure (95% CI, 28.9-138; P<.001) (Figure 3). However, after adjustment for height, this correlation was no longer significant (adjusted hazard ratio, 1.29; 95% CI, 0.89-1.87; P=.18).

Prior history of coronary artery bypass grafting surgery was recorded in 85 patients; the vascular-access-related failure rate in these patients was 14.1% (odds ratio, 1.56; 95% CI, 0.83-2.93; P=.17). In 98 patients with severe aortic stenosis who were catheterized preoperatively, failure rates were similar to the rest of the population (odds ratio, 1.05; 95% CI, 0.54-2.06; P=.88).

The most powerful predictor of vascular-access failure was complete absence of pulse or presence of an extremely weak palpable pulse of the radial artery in the anatomical snuffbox (observed in 8.1% of cases). The failure rate in these cases was 51.6% compared with 6.2% in the rest of cases, where the ldRA was well or very well palpable in the snuffbox (odds ratio, 16.0; 95% CI, 11.2-23.1; P<.001). This association was independent of patient gender and stature (adjusted hazard ratio, 15.8; 95% CI, 10.9-22.8; P<.001).

The rate of postprocedural absence of flow in the left radial artery (absent palpable pulse confirmed with Doppler ultrasound) was 0.2% (3 cases). Persistent postprocedural numbness or pain was reported by 2 patients (0.1%). No serious adverse events (requiring medical or surgical intervention or prolongation of hospitalization) specifically associated with the ldRA approach were reported. Overall adverse event reports included a case of self-limiting dissection of the radial artery and a case of guidewire fracture in the radial artery (the fractured wire had to be removed by a vascular surgeon in the catheterization lab).

Discussion

To our knowledge, the present report summarizes results from the largest case series, of snuffbox ldRA approach as routine primary arterial access in patients scheduled for coronary angiography and/or percutaneous coronary intervention. The ldRA approach was used in a tertiary hospital catheterization laboratory as the default vascular access strategy, without major exclusion criteria.

The overall rate of vascular-access-related procedural failure, requiring transition to a different arterial access, was somewhat higher in this series (9.9%) than the rates historically reported for the radial artery (7% in the RIVAL trial);⁴ however, the rate of failure should be expected to decrease further as operator experience expands. In addition, according to our findings, this rate could be further reduced to levels similar to the proximal radial artery if patients with no or extremely weak palpable pulse in the anatomical snuffbox were excluded (6.2% failure rate when there was a good or very good palpability of the ldRA, which represented 92% of cases). This is in agreement with previous publications in smaller case series.⁵ In any case, the learning process for ldRA access appears to be more demanding compared with the radial and femoral approach due to the smaller size of the distal radial artery.

The physiological basis supporting the use of the distal (vs the proximal) radial artery is compelling considering that the radial artery, before reaching the anatomical snuffbox, has already provided a number of branches that can contribute to forearm and hand blood supply even if the artery becomes damaged or occluded at the snuffbox level.⁶ The potential advantages of the distal radial artery approach are considerable, as it has been proposed to maintain patency of the proximal radial artery, preserve the quality of the radial artery as an arterial graft for future use in coronary bypass surgery, and substantially reduce the rate of postprocedural thrombotic occlusion of the radial artery, since there is no direct trauma from the puncture. The latter point is important, as its rate has been reported to be as high as 15%⁷ or even higher (30%)⁸ with the transradial approach, although a rate of 5%-7% appears to be a more reasonable estimate when an adequate dose of heparin is administered.⁹ Concerns have been voiced over the potential impact of radial artery occlusion on functional aspects of the hand, especially in right-handed patients catheterized through the right radial artery, which is the routine. Although studies on dexterity and muscle strength have been quite reassuring, radial artery occlusion seems to affect significantly the sensory parameters of the hand and may be associated with pain and numbness.^10-12 These effects may be especially important for patients whose work depends heavily on precision and control of the use of their preferred hand. In our series, the rate of postprocedural radial artery occlusion was close to zero, which is in accordance with a previous report in a series of ldRA cases.³

One important advantage of the ldRA approach is the fact that this access is ergonomically advantageous for both the patient and the operator, as it allows the left hand to be conveniently placed at the level of the right lower abdominal quadrant, very close to the right groin. This may increase preference for the ldRA access, as it is far more convenient for the patient (left-hand pronation) and the operator (access point similar to the right femoral approach). An increase in the use of left-sided arterial access may offer considerable advantages, including the fact that the mechanical behavior of the catheters is similar to the femoral approach for which they were designed. Use of the left upper limb for arterial access has also been associated with shorter duration of catheter manipulation and total procedural duration, as well as with shorter fluoroscopy times and lower total dose-area product.^13,14

Study limitations. This was a single-center observational study without a comparator group. Whether true clinical benefit can be derived from using the ldRA access remains to be further evaluated in a randomized clinical trial.

Conclusion

In a large series of consecutive patients scheduled for coronary angiography and/or percutaneous coronary intervention, over a 12-month period, with virtually no exclusions except those few imposed by anatomical or clinical circumstances (eg, previous harvesting of the radial artery or presence of arteriovenous fistula), the ldRA arterial access approach was shown to be feasible, safe, and effective. Further studies are necessary to explore the relative merits and weaknesses of this arterial access approach.   

Affiliations and Disclosures

From the ¹Cardiac Catheterization Laboratory, General Hospital Papageorgiou, Thessaloniki, Greece; ²Cardiac Catheterization Laboratory, Athens General Hospital G. Gennimatas, Athens, Greece; ³Cardiac Catheterization Laboratory, General Hospital of Thessaloniki Agios Pavlos, Thessaloniki, Greece; ⁴2nd Department of Cardiology, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece; ⁵Vascular Department of 1st Surgical Clinic of Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece; ⁶1st Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece; and ⁷Department of Cardiology, Medical School, Democritus University of Thrace, Komotini, Greece.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted October 1, 2021.

Address for correspondence: Georgios Bompotis, MD, General Hospital Papageorgiou, Ring Road of Thessaloniki, Nea Efkarpia, Thessaloniki, 56403, Greece. Email: gebomp@gmail.com

References

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