Using a rigorous protocol of best practices for forearm radial artery occlusion (RAO) prevention, traditional transradial artery access (TRA) and distal radial artery (DRA) access for PCI offered equally low rates of occlusion (0.91% vs. 0.31%, respectively; p=0.29), according to results of the DISCO RADIAL trial presented May 17 at EuroPCR 2022 and simultaneously published in JACC: Cardiovascular Interventions.

Adel Aminian, MD, et al., conducted DISCO RADIAL, a large, randomized multicenter trial with 1,307 patients from Europe and Japan designed to randomly compare the efficacy and safety of conventional TRA against DRA, with both groups also assigned to systematic implementation of best practices to reduce RAO. DRA has been proposed as an alternative to TRA because of its lower incidence of RAO.

Results showed that the DRA approach was associated with a higher crossover rate (7.4% vs. 3.5% for transradial access; p=0.002) and more radial artery spasm (5.4% vs. 2.7%; p=0.015) but shorter median hemostasis time (153 vs. 180 min; p<0.001) and a similar incidence of vascular complications.

European and American guidelines have established TRA as the gold standard for invasive coronary angiography and PCI owing to its clear superiority over transfemoral access. But RAO remains the "Achilles heel" of the TRA approach, seen in up to 8% of patients at one week post procedure (although spontaneous recanalization is noted in about half of patients at 30 days). According to the authors, RAO is not generally clinically meaningful, but an occluded radial artery precludes its use for future intervention or as a conduit for coronary artery bypass grafting.

"Conventional TRA remains the gold standard vascular access provided thorough compliance to best practice recommendations for RAO avoidance, which establishes [it] as a mandatory new reference in transradial practice," write the authors. "At the same time, DRA emerges as a valid alternative developing on a noteworthy trade-off between a more demanding and uncertain arterial puncture and a safer and simpler post-procedural vascular access care."

"Forearm RAO was surprisingly low in both arms, but especially in TRA arm," note Grigorios Tsigkas, MD, PhD, and colleagues, who provided an editorial comment on the trial. They suggested that the 0.91% rate seen in this trial with TRA could be pushed even lower had the investigators administered a more evidence-based anticoagulation regimen.

"To the best of our knowledge, it is the lowest RAO incidence in a such large-scale trial in the existing literature, showing that the systematic implementation of best practices for RAO prevention could drive to amazing results," they conclude.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, Aortic Surgery, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: ACC International, Radial Artery, Coronary Angiography, Percutaneous Coronary Intervention, Incidence, Punctures, Coronary Artery Bypass, Anticoagulants, Spasm, Hemostasis, Catheterization, Peripheral, Arterial Occlusive Diseases

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