Distal transradial access in the anatomical snuffbox for diagnostic cerebral angiography

Abstract

BackgroundThe transradial approach for endovascular angiography and interventional procedures is superior to the traditional transfemoral approach in several metrics, including lower access-site complication rates, higher patient satisfaction, and lower hospital costs. Interventional cardiologists have begun to adopt the distal transradial approach (dTRA) for coronary interventions as it has an improved safety profile and improved procedural ergonomics. Adaptation of dTRA for neuroendovascular procedures promises similar benefit, but requires a learning curve.ObjectiveTo report the first use of dTRA for diagnostic cerebral angiography and demonstrate the feasibility and safety of a dTRA.MethodsA retrospective review of our prospective institutional database of consecutive cases of cerebral DSA performed via dTRA between August 2018 and December 2018 was performed. Patient demographics, procedural and radiographic metrics, and clinical data were recorded.Results85 patients were identified with an average age of 53.8 years (range 18–82); 67 (78.8%) patients were female. 78 patients underwent successful dTRA diagnostic cerebral angiography, with a mean of five vessels catheterized and average fluoroscopy time of 12.0 min, or 2.6 min for each vessel. Seven patients required conversion to transfemoral access, with the most common reason being inability to advance the wire and radial artery spasm. There were no complications.ConclusiondTRA is associated with decreased rates of radial artery occlusion, ischemic hand events, as well as improved patient comfort, faster periprocedural management, and cost benefits. Our preliminary experience with dTRA for diagnostic cerebral angiography demonstrates excellent feasibility and safety in combination with relative efficiency.

Distal Radial Artery Access: The Future of Cardiovascular Intervention

“…Distal radial access can also be used for interventions other than cardiac, and a study in 2017 demonstrates using this approach in 50 visceral interventions [33]. Another case series study in 2019 on 85 patients demonstrates the feasibility of this approach as diagnostic in cerebral angiography [34]. Distal radial access is used for proximal RAO even if it associated with acute coronary syndrome, based on a case reported recently [33].…”

Complications of femoral versus radial access in neuroendovascular procedures with propensity adjustment

“…Several advantages of the transradial artery (TRA) approach established in neurointerventional studies include a more direct access to the vertebrobasilar system, greater ease navigating complex arch anatomy such as bovine and type III arches, and robust collateral circulation from the ulnar artery leading to fewer ischemic (often clinically silent) complications 17–19. Variations to the traditional proximal radial access now exist, including distal radial artery access within the anatomic 'snuffbox' (radial fossa) 20. Among its many advantages, this technique allows arterial access distal to the branch point of the superficial palmar branch supplying collaterals to the deep palmar arch of the hand; theoretically, this approach decreases the risk of an ischemic complication even further 20.…”

Gaining momentum

“…This month’s JNIS features further validation of the safety and efficacy of the transradial approach in the endovascular treatment of cerebrovascular disease 1. Building on their previous work, also published in the JNIS , Brunet and coauthors report their experience in diagnostic cerebral angiography employing the snuffbox approach 2 3.…”

“…By entering the deep palmar branch of the artery, this distal approach lessens the likelihood of injury to the superficial palmar branch, which originates more proximally along the course of the radial artery and forms an important anastomosis with the ulnar artery 1. Furthermore, given the trajectory of the distal radial artery, the patient’s arm can be placed in an ergonomically natural position with the palm facing the hip.…”

“…In their experience with 85 patients, the authors successfully performed diagnostic cerebral angiography in 78 (92%) 1. The remaining procedures were converted to either a standard transradial catheterization or a transfemoral approach.…”