Distal radial access in coronary procedures: a systematic review and meta-analysis of randomized clinical trials over the past 20 years

Abstract

Distal radial access (DRA) is promoted to reduce the incidence of radial artery occlusion (RAO) after interventional coronary procedures while preserving the be­nefits of the classic radial artery approach. Despite the rapid adoption of this technique, the clinical utility of DRA in various clinical scenarios (coronary angiography, elective percutaneous coronary intervention (PCI), acute coronary syndrome, and primary PCI for ST-segment elevation myocardial infarction) remained heterogeneous due to differences in surgeon experience, hemostasis protocols, and occlusion verification methods. Aim . To systematically search and critically analyze randomized clinical trials (RCTs) of DRA in interventional coronary interventions over the past 20 years, with a separate description of excluded non-randomized sources and se­condary reviews. Material and methods . A search was performed using the PRISMA 2020 criteria in PubMed, Web of Science, Google Scholar, and eLIBRARY. A supplementary search of reference lists and ClinicalTrials.gov was also conducted. The main synthesis included only RCTs in adult patients comparing DRA with traditional radial access for coronary angioplasty and/or PCI. Retrospective studies, case-control studies, case reports, and secondary reviews were excluded from the primary synthesis but were reflected in separate tables. Results . The qualitative synthesis included 15 RCTs, and the quantitative meta-ana­lysis included 12 RCTs with an extractable number of events for RAO. In the pooled analysis, DRA significantly reduced the risk of RAO compared with the traditional approach (RR 0,29; 95% CI 0,21-0,40; I2=4,1%) but was associated with a higher probability of access conversion/failure (RR 2,59; 95% CI 1,34-5,00). Conclusions . The most consistent advantage of DRA was observed in reducing hemostasis time and incidence of RAO, especially in studies with Doppler verification and standardized (patent) hemostasis. For primary PCI of STEMI, DRA appears feasible in experienced centers. However, it should not prolong the time to reperfusion and requires readiness for rapid conversion to the traditional radial or femoral approach.