الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
According to the World Health Organization, coronary artery disease is the leading cause of death worldwide. However, advancements in percutaneous coronary intervention (PCI) techniques and devices in the diagnosis and treatment of this disease have significantly reduced the mortality rate. Among these methods, procedural access has shown significant improvement.
Current European and American guidelines recommend transradial access (TRA) as the default approach for cardiac catheterization, based on solid evidence demonstrating benefits in terms of major bleeding, vascular complications, and all-cause mortality over transfemoral access (TFA) in patients undergoing coronary angiography and/or percutaneous coronary intervention (PCI).
The widespread adoption of TRA, prompted by technical advancements and a steady increase in operators’ expertise with that access site, paved the way for new approaches for cardiac catheterization with the lofty goal of preserving the benefits of TRA while mitigating potential access site-related complications such as forearm radial artery occlusion (RAO), major bleeding, pseudoaneurysms, or arteriovenous fistulas.
Although the presence of RAO has no clinical implications, it is still undesirable because it limits the use of the radial artery for future coronary procedures, such as coronary artery bypass grafting or the formation of arteriovenous fistulas in hemodialysis patients.
Recently, Babunashvili and Dundua described the distal radial access (DRA) in order to open occluded ipsilateral radial arteries retrogradely. Then, in 2017, Kiemeneij developed it for coronary catheterization and In recent years, the growing ”radial-first” strategy has gained traction, particularly on social media, pushing the limits of TRA in the anatomical snuffbox or the dorsal hand for both coronary and noncoronary procedures.
Distal TRA has some potential advantages over conventional TRA in terms of physiological and anatomical reasons.
First, a puncture distal to the superficial palmar arch allows anterograde flow in the forearm radial artery to be maintained during hemostatic compression or in the event of occlusion at the puncture site, lowering the risk of RAO. Flow interruption during the hemostasis process has been identified as a key player in the evolution of RAO.
Second, a shorter hemostasis time due to the distal radial artery’s more superficial position may further reduce the risk of RAO. Finally, distal TRA has been linked to increased patient and operator comfort during the procedure, particularly in the case of left distal TRA.
Despite the theoretical benefits, available evidence is limited to registry data and small randomized controlled trials assessing the feasibility and preliminary efficacy of distal TRA. As a result, large-scale, adequately powered randomized trials are required to inform an evidence-based approach to access site selection.
Certainly, the success of this approach is dependent on anthropometric characteristics of the population and the experience of the operators, and it must be evaluated in real life and under various conditions.
from this point, we tried at cardiology department, Alexandria University to launch
a ”Real-life” study about D-TRA approach for the first time in Egypt.
We tried to make our own experience by converting the theoretical concepts about this new approach into a clinical practice, and explore its advantages and drawbacks compared by the inherent conventional TRA approach, to finally form a solid conclusion based on scientific measures about its viability and feasibility as a possible access site option in the coronary intervention field.
Our study is a prospective, randomized, single center study comparing two methods of obtaining radial access in patients undergoing coronary intervention according to primary and secondary endpoints. 100 patients who were admitted at cardiology department facilities were enrolled in the study after applying inclusion and exclusion criteria, and then were randomized into two arms using systematic random sampling method, coronary interventions in the first arm was done via D-TRA (50 patients) and in the second arm via TRA (50 patients).
Procedures were undergone by operators who have a credible experience in radial approach with a reasonable proficiency in the distal radial access.
Approval of the ethics committee of the faculty of medicine, university of Alexandria with serial number 0106762/2020 was guaranteed and written informed consents were signed by the patients or their guardians after full explaining of the study aims and technical aspects.
The study started from April 2020 to October 2021. Data was gathered carefully from the 100 patients enrolled in the study divided into 2 arms of the comparison; D-TRA group and conventional TRA group (50 patients for each group).
Results were obtained and tabulated under two groups or two arms; group (I) represents patients in whom D-TRA was used and group (II) represents patients selected for conventional TRA.
Comparing demographic data, basic characteristics and clinical indications between two groups, there were no statistically significant differences between groups.
There were highly statistically significant differences between groups with higher successful procedural and cannulation rate in group II (TRA) than group I (D-TRA). P= 0.002 and 0.025 respectively.
As regard group (I), the procedural success and cannulation success rates shows statistically significant differences between both sexes as males show procedural success rate of 86.2% (25 patients out of 29) and cannulation success rate of 93.1% (27 patients out of 29). In contrast to females who completed the procedure successfully in only 12 patients out of 21 (57.1%) and the cannulation was successful in only 14 patients out of 21 (66.7%) of D-TRA group. P= 0.021 and 0.025 respectively.
In our patients of D-TRA group, 21 procedures were done during urgent settings (ACS), with 14 procedures were completed successfully (66.7%), while in TRA group, 26 out of total 27 procedures (96.3%) were completed successfully. Despite the numerical advantage in favor of TRA group, there was no statistically significant difference between two methods. P= 0.314. P= 1.00 respectively.
Our results reveal that out of the total 50 patients in D-TRA group, 21 procedures were done during urgent settings, 14 procedures were completed successfully with procedural success rate of 66.7%. While 29 procedures were done through elective settings, 23 procedures were completed successfully with success rate of 79.3%. So we can conclude that there was no statistically significant difference between the two different settings which gives us a valid impression that the D-TRA approach can be used during urgent settings of coronary interventions in ACS.
There were highly statistically significant differences between groups as the right side was the more frequently selected side in TRA group, while the left side was obtained more in the D-TRA group than the conventional TRA group. P= 0.001
Number of punctures attempts distribution in group (I) was ranged between 1.0 – 6.0 attempts with a mean value of 2.16 ± 1.25 attempts while in group (II) it was ranged between 1.0 – 5.0 attempts with a mean value of 1.54 ± 0.91 attempts. There were highly statistically significant differences between groups. In other words it takes more punctures attempts to gain access in D-TRA group than it takes in TRA group. P= 0.003
Our results show that we could cannulate the arterial access in the conventional TRA group (group II) successfully from the first attempt in 64.4% of cases vs. only 41.5% of cases in D-TRA group (group I)
And we could start and complete the procedure successfully from the first puncture attempt in 64.4% of cases in group (II) via conventional TRA vs. only 43.2% of cases in group (I) via D-TRA, which gives us a reflection about how feasible the conventional TRA is compared to the D-TRA.
There were highly statistically significant differences between groups with access time higher in group (I) than group (II) reflecting the longer time it takes to access the radial artery distally than proximally. P= 0.001
There were highly statistically significant differences between groups with total procedural time higher in group (I) than group (II). This significance is mostly due to the longer access time in D-TRA group but the operative steps after obtaining access are quiet similar in the two methods. P=0.018
There were highly statistically significant differences between groups with Post procedural compression time longer in group (II) than group (I), mirroring faster hemostasis in D-TRA group than hemostasis in TRA group. P= 0.001
In group (I) there were 13 times (26.0%) when the operator cross over to another access site versus only 2 times (4.0%) in group (II) with highly statistically significant differences between groups in favor of TRA group in which it was less needed to cross over to another access site than D-TRA group. P= 0.002
There were highly statistically significant differences between groups according to Radial artery occlusion which was higher in TRA group than D-TRA group. P=0.012. There was no statistically significant difference regarding the occurrence of other access site complications between the two groups.
Concerning patient satisfaction, when asked patients of both groups if the procedure was quietly satisfactory for them, 47 patients (94.0%) of group (I) were satisfied, and 46 patients (92.0%) were satisfied as regard the second group, with no statistically significant differences between groups according to that concern. P= 1.000
from our first own experience at Alexandria university, we can conclude that in the field of coronary intervention, the distal radial artery approach is a very promising and interesting technique and it can be a real possible access site option.