Distal Transradial ApproachA new way of puncture?

Dr. Giovanni Amoroso

OLVG Amsterdam

A new way of puncture!

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Superficial palmarBranch

Radial ArteryUlnar Artery

Deep PalmarArch

Dorsal viewVolar view

SnuffBox

True DTRARadial Artery

Distal Right Radial

Sheathless 5F Medikit

Footage taken at OLVG with permission

https://www.slideshare.net/theradialist/11-aimradial2016-thu-babunashvili-a

Dr A Babunashvili – Moscow

First description of distal radial puncture

Dr F Kiemeneij – Blaricum

First publication on distal radial approach (Eurointervention 2017)

8Capodanno D EuroIntervention 2018

#radialfirst#ldtra

Rationale for DTRA

• Comfort for the patient

• Comfort for the operator

• Secondary clinical outcomes

Comfort for the patient

• No wrist immobilisation after procedure

• Shorter hemostasis (day-care!)

• Only for Left DTRA: dominant hand (mostly right) unaffected

Comfort for the operator(only for Left DTRA)

• Stand at the Right side of table

• Less anatomical abnormalities/easier coronary cannulation (?)

Secondary Clinical Outcomes

• Preservation of RA in case of distal occlusion

– A-V Shunts (dialysis)

– arterial Grafts (CABG)

–Repeated Interventions

• Lower rates of occlusions

• Less complaints/incidence of Upper Extremity Dysfunction (UED)?

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In case of right approach put the arm on its sideIn case of left approach put the hand palm down on the crotch

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My first case – May 29th 2017

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Keep it simple!

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1. a. Position left hand on the crotchb. Position right hand on the side

2. Hyperextend the wrist3. Give Lidocaine (3-5 cc)4. Use needle-cannula (transfixion kit)

and hydrophilic wire5. Extend the elbow before crossing6. Be gentle and patient!

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Thumb

Pink

Pitfalls

• Low puncture

Radial Artery

Palmar Arch

Cannula

0.014” wire to Radial Artery

Pitfalls

• Arterial bends

Conventional Puncture Site

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knot in the Distal Radial Artery

Cannula

330.014” Wire in Radial Artery

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Echo-guided puncture

Kiemeneij, Eurointervention 2017

Advantages

• Bail out in case of failed conventional approach

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Dissection after conventional TRA

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Advantages

• Recanalisation of RAO

Cannula

Radial Artery Occlusion

Straight Terumo 0.021” through the cannula

Angiography once 5F Glidesheath Slender inserted

Advancement of 0.014” coronary wire up to upper arm

Advancement of 5F Guiding Catheter (BAT Technique)

Radial artery successfully recanalised

Risks?

Avascular Necrosis of the Scaphoid Bone

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SafeGuard Radial 5-6 cc

+/- StatSeal DIsc

Remove after one hour

My Hemostatic Technique (1)

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5F Sheathless PCI Medikit

Compression with SafeGuard Radial

6 cc, one hour

Footage taken at OLVG with permission

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TR Band XL 10 cc

Remove the hard support

Remove after one hour

My Hemostatic Technique (2)

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5F Sheathless PCI

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• 70 patients• 61% Angio 39% PCI/FFR

• 11% failure• 0% major bleedings• 1.5% dRAO

Kiemeneij F, EuroIntervention 2017

Are there scientific evidences?

59Jun-Won Lee et al, EuroIntervention 2018

Access-Site Complications: Postprocedural and 1-month Follow-Up

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Learning Curve with Distal Transradial Access

Jun-Won Lee et al, EuroIntervention 2018

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Conclusions• Distal TRA seems a valid alternative to

conventional transradial approach, with the additional advantages of:• Increased comfort for both patient and

operator (in case of left distal approach)• Reduced incidence/impact of RAO

• Distal TRA seems a feasible approach for treating RAO

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Back – up slides

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