Distal radial artery access (DRA) is recommended as the preferred approach over the traditional proximal radial artery access (TRA) for coronary procedures; however, there are limited randomized controlled trials (RCTs) that compared the 2. We conducted an updated meta-analysis of all RCTs from inception to July 26, 2021, that compared DRA versus TRA in patients who underwent coronary procedures. The statistical analysis was performed using a random effect model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). A total of 5 RCTs were included with a total of 1,005 patients. A pooled analysis of the data showed that the rate of successful cannulation was similar between the 2 arms (RR 0.85, 95% CI 0.68 to 1.07, p = 0.16, I 2 = 94%). The rate of radial artery spasm significantly favored the DRA arm as compared with TRA (RR 0.51, 95% CI 0.34 to 0.75, p = 0.0007, I 2 = 0%). Significantly more patients from the DRA arm required alternative arterial access. Moreover, the DRA group had an insignificantly decreased rates of radial artery occlusion (RR 0.24, 95% CI 0.05 to 1.20, p = 0.08, I 2 = 46%) and early discharge after transradial stenting of coronary arteries access-site hematomas (RR 0.52, 95% CI 0.18 to 1.149, p = 0.22, I 2 = 0%). The mean time for hemostasis was significantly shorter in the DRA arm (mean difference −6.64, 95% CI −10.37 to −2.90, p = 0.0005, I 2 = 88%). In conclusion, DRA should be considered as a viable, effective, and safe arterial access method for patients who underwent coronary procedures.
A recent meeting in December 2019 was held by the Korean CHORUS congress along with European specialists and discussed the topic of transradial access. Their consensus was that for percutaneous coronary procedures distal radial artery access (DRA) provides more beneficial outcomes than the traditional proximal radial artery access (TRA), such as lower rates of radial artery occlusion (RAO) and vascular complications, faster hemostasis, and favorable ergonomics. However, they indicated that this recommendation should be followed up based on the outcomes of randomized controlled trials (RCTs). To address these aforementioned unknown issues in the current guidelines, we conducted an updated meta-analysis with the addition of 2 recently published RCTs that compared DRA versus TRA for patients who underwent coronary procedures.
Methods
We conducted a comprehensive review of previous publications of all relevant studies from inception to July 26, 2021. We searched the electronic databases of PubMed, EMBASE, and COCHRANE for RCTs. The inclusion criteria consisted of: (1) an RCT that evaluated the efficacy and/or safety outcomes of DRA versus TRA for coronary procedures, (2) the study reported more than 1 clinical or safety outcome, (3) human subjects, and (4) no restriction to language. Exclusion criteria were (1) follow-up data in <90% of patients, (2) ongoing or irretrievable data, (3) no clinical outcome end point. This meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines ( Figure 1 ).
The search included the following keywords: “radial artery,” “distal,” “proximal,” “conventional,” “transradial,” “coronary procedures,” “randomized trial.” Two authors (RMP and PP) independently reviewed the search results, extracted potential articles, and assessed their eligibility. The Cochrane Collaboration risk-of-bias tool was used by 2 different authors (RMP and PP) to assess the quality of the included studies.
The primary outcome was a successful cannulation rate. The secondary outcomes were the rate of radial artery spasm (RAS), RAO, crossovers to alternative arterial access, early discharge after transradial stenting of coronary arteries (EASY) access-site hematomas, and the mean time for hemostasis. We also collected baseline characteristics of the study and patients.
Statistical analysis was conducted using Review Manager (RevMan), version 5.4 (The Cochrane Collaboration, Copenhagen, Denmark). The Mantel-Haenszel random-effects models were used to estimate the risk ratio (RR) and mean difference along with the corresponding 95% confidence intervals (CI). Two-sided p <0.05 were considered statistically significant. I 2 statistics were used to assess statistical heterogeneity.
Results
A total of 5 RCTs were included with a total of 1,005 patients ( Figure 1 ). The characteristics of the included studies and patients are described in Tables 1 and 2 . Of note, 3 studies made the assessment of RAO at discharge. , , However, Eid-Lidt et al recorded the rate of RAO at 24 hours and 30 days. Due to the initial articles only recording the rate at discharge, only the information from Eid-Lidt et al after 24 hours was used to keep the timeline similar. Additionally, Koutouzis et al reported EASY access-site hematomas that were grade >3; whereas, Lucreziotti et al reported them as grade >2.
| Study | Publication year | Study name | Country | Centers | Sample Size | Sheath (type, n) | Medications to prevent RAS | Approach to hemostasis | Timing of RAO assessment |
|---|---|---|---|---|---|---|---|---|---|
| Mokbel | 2018 | None | Romania | Single | 114 | NS | Nitrate | NS | At discharge |
| Koutouzis | 2019 | None | Greece | Multi | 200 | 6-French: 200 | Verapamil | Manual compression | At discharge |
| Vefali | 2020 | None | Turkey | Single | 205 | 5-French: 205 | NS | Manual compression | NS |
| Eid-Lidt | 2021 | DAPRAO | Mexico | Single | 282 | 6-French: 256 | NS | TR-band | After 24 hours and 30 days |
| Lucreziotti | 2021 | None | Italy | Single | 204 | 6-French: 199 7-French: 5 | NS | TR-band | At discharge |
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