Distal Radial Artery PCI Access Doesn't Hurt the Hand

ATLANTA -- Radial artery access for cardiac catheterization appeared similarly safe for the hand whether done proximally or distally, the randomized DIPRA trial showed.

Overall change in 30-day hand function z-score declined by 0.04 in the distal group and increased 0.10 in the proximal group, without a significant difference from baseline in either group or between groups (P=0.07), reported Karim Al-Azizi, MD, of Baylor Scott & White's the Heart Hospital-Plano in Texas.

There was a trend for a differential change in pinch grip strength as a component of the hand function composite endpoint (-0.2 vs 0 kg change from baseline, P=0.05), Al-Azizi noted in presenting the findings at a featured clinical research session here at the Society for Cardiovascular Angiography and Interventions (SCAI) annual meeting.

However, when looking at patients' other hand that had not been catheterized, the same was true, Al-Azizi said. "Systemic diseases can affect one way or the other, just as an index of frailty can vary on a good day and on a bad day."

Risk of radial artery occlusion, which can jeopardize subsequent use for procedures or for dialysis, has been one rationale for the distal approach, along with easier ergonomics for the operator.

The DISCO RADIAL randomized trial, presented just days earlier at the EuroPCR meeting in Paris, showed similar rates of radial artery occlusion between the two access routes (0.91% proximal vs 0.31% distal, P=0.29) among patients undergoing diagnostic coronary angiography, percutaneous coronary intervention (PCI), or both.

In that trial, distal radial procedures were associated with more radial artery spasm (2.7% vs 5.4%, respectively, P=0.015) but not more pain.

No radial artery occlusion occurred in the distal access group in DIPRA.

"It's great to have more options," said session co-moderator Sunil V. Rao, MD, of Duke University Hospital in Durham, North Carolina, calling the DISCO RADIAL trial findings remarkable for the "very, very low" rate of complications. "I think it's going to be challenging to do trials now with radial artery occlusion as an outcome."

The newer distal approach has left patients with questions, though, said session panelist Jacqueline Tamis-Holland, MD, of the Icahn School of Medicine at Mount Sinai in New York City. "I have patients who are pianists, and they want to know will this be a problem."

No individual patients reported impairments in hand function on the DASH survey, including those who make their living through fine motor skills, Al-Azizi noted.

"It reassures us, because there has always been the question. It's close to the radial nerve, it's a very small area. What is it going to do to people, for example, who are interventionalists, who do procedures," he said at a press conference.

Still, "this is not an access for everybody," Al-Azizi acknowledged at the session. There is a learning curve to the more complex approach, which ultrasound guidance can ease, and patient selection is important, he said.

Some 85 patients were excluded from participation due to insufficient palpable pulse or radial artery size.

DIPRA included 300 randomized patients with a mean age of 66.6, among whom 32% had diabetes mellitus, 77% had hypertension, and 19% had prior PCI. Radial artery catheterization in the prior year was an exclusion criterion.

Which hand was used for access, dominant or non-dominant, was left up to patients.

The primary composite endpoint included hand grip and thumb-to-forefinger pinch grip strength, as measured before and after the procedure with a dynamometer, as well as the QuickDASH survey, typically used in occupational therapy for self-reporting hand function in daily use scenarios, like opening a jar.

The trial showed no difference between the distal and proximal groups in bleeding (0% vs 1.4%, P=0.25) or in successful radial artery access (96.7% vs 98%, P=0.72).

The six distal radial group patients who had to crossover to another access route were all successfully converted to proximal radial artery access, noted Al-Azizi. "This is great news. It means you don't have to prep a whole lot for these patients." The four proximal radial patients with crossover had to switch to femoral artery access.

His group will continue to follow long-term outcomes to 1 year for the DIPRA patients.

One limitation to the study was that only 25% of the participants were women, a group that often has smaller radial arteries and is more prone to vasospasm, noted session co-moderator Alexandra J. Lansky, MD, of Yale University in New Haven, Connecticut.

While a small sample, not all of the access failure was in women, Al-Azizi responded. "In a good radial artery, regardless of sex, when you choose the right patient with the right size and palpate the artery, you will be successful."

Comment