Distal artery access PCI safe vs. proximal access at 1 year; no impact on hand function
Key takeaways:
- Distal radial access — behind the thumb — PCI did not affect hand function at 1 year vs. traditional proximal access.
- The safety and efficacy of the two approaches were also similar.
Distal radial artery access for PCI showed no significant change in hand function and similar rates of access-site bleeding and radial artery occlusion at 1 year vs. proximal access, a speaker reported.
The 1-year outcomes of the DIPRA trial were presented at the Society for Cardiovascular Angiography and Interventions Scientific Sessions.
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“Proximal radial artery access for cardiac catheterization has been shown to be safe and with a mortality benefit. Radial artery access is now a class I indication for PCI and ACS patients with known benefits to reduce risk of death, vascular complication and bleeding. But compared to proximal radial artery access, there has been an emerging interest in distal radial artery access,” Karim Al-Azizi, MD, FSCAI, interventional cardiologist at The Heart Hospital in Plano, Texas, part of Baylor Scott and White Health, said during a press conference. “That part of the artery being accessed in the anatomical snuff box has the potential of preserving that artery in general in lower radial artery occlusion rates described in several registries and studies with good safety short-term outcomes at 30 days. Yet, long-term outcomes of its safety and effects on hand function remain unknown.”
Although radial artery access received a Class I indication for PCI for patients with ACS and those with stable ischemic heart disease, Al-Azizi and colleagues hypothesized that distal radial artery access may be a better option for preserving the artery compared with proximal access.
DIPRA was a single-center, prospective, randomized controlled trial that enrolled 300 patients undergoing PCI (mean age, 67 years; 75% men; 19% with prior PCI) to evaluate 30-day hand function outcomes following a distal approach compared with proximal radial artery access for the procedure.
As Healio previously reported, 30-day hand function did not differ between distal compared with proximal radial artery access for PCI, and distal access was deemed a safe alternative to proximal access, with low a complication rate.
For the present study, Al-Azizi and colleagues evaluated hand function, success rate, access site complications and radial artery occlusion in 216 patients who completed 1 year of follow-up. Of those, 112 patients were assigned to distal access and 104 to proximal access.
At 1 year, researchers observed no significant difference in the change of hand function between the two groups (P = .59), including secondary measures of hand function such as:
- change in hand grip strength (P = .59);
- pinch grip strength (P = .66); and
- QuickDASH Survey Score (P = .58).
Access-site bleeding was similar between the two groups (distal access, 0%; proximal access, 1.4%; P = .25).
Moreover, radial artery occlusion occurred in one patient who underwent proximal artery access PCI and two who underwent distal artery access PCI.
“This is the first randomized, controlled study to date to evaluate hand function after distal radial artery access vs. proximal radial artery access. There's similar rates of success between both in our study with very low crossover rates,” Al-Azizi said during the press conference. “There were no bleeding or hematoma noted in the distal radial cohort and compared to proximal radial artery access, there was no increased risk of hand dysfunction at 30 days as previously noted, but also up to 1 year. So, in carefully selected patients, distal radial artery access is safe compared to proximal radial artery axis.”
Perspective
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DIPRA was a well-done study. Radial access has dramatically increased but there is limited research on distal access and no direct comparisons.
There is a bit of a learning curve when learning distal radial access, but these trial results should encourage more interventional cardiologists to do it. Both access sites had low bleeding, but there was a trend toward less bleeding with distal access. Some were worried about hand weakness due to distal access but these results demonstrate the safety.
There are many reasons to consider distal access, but in particular, it expands your ability to do left radial. If you think about your arms, you’re lying on the table, and if you put your left arm across your chest, what’s in front of you is the snuffbox. This is a terrific advantage for left radial. The DIPRA trial shows that it is safe; it might even be a little bit better; and expands our ability to do radial, in particular left radial.
The only weakness of the DIPRA trial from my standpoint was too many patients lost to follow-up — more than 15%.
What this trial should do is prompt more people to learn distal access and encourage uptake. I like this study a lot. It is worth talking about and it extends our ability and safety of doing radial access.
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Al-Azizi K, et al. Late-Breaking Presentation II. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; May 18-20, 2023; Phoenix.
