Table of Contents
GUIDELINE AND CONSENSUS
Year : 2020  |  Volume : 5  |  Issue : 4  |  Page : 175-185

Chinese expert consensus on percutaneous coronary intervention through distal transradial artery access


, China

Date of Submission09-Nov-2020
Date of Acceptance17-Nov-2020
Date of Web Publication30-Dec-2020

Correspondence Address:
Chinese Expert Consensus Group for Percutaneous Coronary Intervention through the Distal Transradial Artery Access; Thumb Club
Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2470-7511.305423

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How to cite this article:
Chinese Expert Consensus Group for Percutaneous Coronary Intervention through the Distal Transradial Artery Access; Thumb Club. Chinese expert consensus on percutaneous coronary intervention through distal transradial artery access. Cardiol Plus 2020;5:175-85

How to cite this URL:
Chinese Expert Consensus Group for Percutaneous Coronary Intervention through the Distal Transradial Artery Access; Thumb Club. Chinese expert consensus on percutaneous coronary intervention through distal transradial artery access. Cardiol Plus [serial online] 2020 [cited 2021 Jun 23];5:175-85. Available from: https://www.cardiologyplus.org/text.asp?2020/5/4/175/305423




  Introduction Top


The transfemoral artery access is the classic access for coronary angiography (CAG) and percutaneous coronary intervention (PCI), as well as the initial access for PCI. With continuous development of tools for the diagnosis of coronary artery diseases and treatment technologies, transradial artery access (TRA) has been proven to be superior to transfemoral artery access.[1],[2] Compared to the transfemoral artery access, TRA can significantly reduce vascular complications such as bleeding[3] and ensure better patient comfort.[2] It can also reduce the mortality of patients with acute coronary syndrome.[4] Therefore, currently, over 90% of the CAG and PCI operations in the Chinese mainland are performed through TRA.[5],[6]

However, the problem of radial artery occlusion due to TRA has gradually been recognized, with a 0%–33% reported rate of occlusion of varying degrees, which has limited the repeated use of the radial artery on the operation side.[7],[8] Besides, the drawback of a relatively inconvenient operation through TRA on the left side has often been mentioned.[9] In 2017, Kiemeneij[9] first reported the clinical research on PCI through the distal TRA (dTRA) in the left nasopharyngeal fossa in English. dTRA has gradually attracted attention, and some subsequent clinical observations have also found that it ensures a relatively good patient experience, shortens the postoperative compression time, significantly reduces radial artery occlusion rate, etc.[9],[10],[11],[12] As a result, several coronary care centers have begun to opt dTRA for PCI. At present, many hospitals in Shanghai, Beijing, Tianjin, Guangdong, Hebei, Zhejiang, Xinjiang, Henan, Fujian, Shandong, Anhui, Jiangxi, Heilongjiang, Liaoning, Inner Mongolia, Jiangsu, Henan, Guizhou, Sichuan, Hubei, and Yunnan, as well as other provinces and cities, have successively performed dTRA and gathered a good preliminary experience. To promote the standardized and safe implementation of dTRA in China, 54 experts from the Chinese Expert Consensus Group for PCI through the dTRA and the Thumb Club jointly formulated this consensus.




  Current Status of Accesses for Percutaneous Coronary Intervention Top


Transfemoral artery access

Sones[13] first performed aortography through brachial artery incision in 1958, and Judkins[14] first performed CAG by puncturing the femoral artery in 1967, which ushered in the era of the diagnosis and treatment of coronary artery diseases through transfemoral artery access. Femoral artery puncture is the classical route for CAG and PCI. This procedure is characterized by a large diameter, easy pulse palpation, high operation success rate, and a more convenient and flexible surgical technique. However, due to the deep location, large diameter, and rapid blood flow of the femoral artery, various complications, such as hemorrhage and hematoma, can occur, and patients need to be on bed rest for a long time after the operation, thereby increasing the risk of lower limb thrombosis and pulmonary embolism.[15]

Proximal transradial artery access

Campeau first reported CAG through TRA in 1989.[16] Subsequently, Kiemeneij et al.[17],[18] reported percutaneous coronary balloon angioplasty and stent implantation through TRA in 1993, and Wu et al.[19] reported the application of TRA for CAG and angioplasty in the Chinese population in 1997. In the last 20 years, TRA has developed rapidly, and coronary artery disorders that can be treated through TRA have been expanding daily, such as left main coronary artery diseases, severe calcification diseases, chronic total occlusions (CTOs). Based on the advantages of TRA, such as no need for postoperative immobilization; improved patient comfort; significantly reduced complications, such as hemorrhage and hematoma; shortened hospital stay; and reduced overall medical expenses,[15] TRA was recommended as the first-choice access for coronary artery diagnosis and treatment by the Guidelines on Myocardial Revascularization of the European Society of Cardiology in 2018.[20] However, complications such as radial artery occlusion, hematoma, pseudoaneurysm, arteriovenous fistula, and osteofascial compartment syndrome caused by TRA are still need to be resolved.[21]

Distal transradial artery access

As early as in 2011, Babunashvili and Dundua reported two cases in which the occluded proximal radial artery was reversely opened by dTRA through the nasopharyngeal fossa,[22] and dTRA was introduced into the field of intervention for the first time. In 2014, Kaledin published an article on intravascular PCI via dTRA in Russia[23] and presented a report at the Congress of the European Association of Percutaneous Cardiovascular Interventions. Since then, dTRA began to attract attention, but in a limited scope. A clinical study by Kiemeneij[9] in 2017 confirmed the safety and feasibility of PCI through dTRA. In 2019, Wretowski et al.[24] reported PCI performed through dTRA at the anatomical location of the nasopharyngeal fossa (known as the region of the Hegu acupoint in China[25]) where the abundant bony structures facilitate puncture point localization and postoperative compression hemostasis.


  Advantages and Disadvantages of Distal Radial Artery Puncture Top


Advantages

By virtue of the emergence of ultra-thin hydrophilic artery sheath, the diameter of the distal radial artery in most patients can be matched with 6F radial artery sheath, 7F radial artery thin-walled sheath, or 8F sheath-free catheter.[26],[27] Therefore, all PCI techniques that could previously be performed through TRA, such as rotational atherectomy and kissing balloon inflation, can be completed by dTRA. Compared to TRA, dTRA offers unique advantages [Table 1]: first, the distal radial artery is relatively superficial, and there are more bony structures around the artery, which significantly reduces the postoperative compression time[28] and bleeding complications.[29] In addition, as compression hemostasis for the distal radial artery does not block the veins, the risks of hand hyperemia and osteofascial compartment syndrome are significantly reduced.[30] Second, the incidence of distal radial artery occlusion caused by dTRA is significantly lower than that caused by TRA, and because of the presence of the superficial palmar arch, even if the distal radial artery has slower blood flow or is occluded, it does not affect the forward blood flow of the radial artery.[31] Therefore, dTRA hardly causes radial artery occlusion, which reduces damage to the radial artery, retains a potential “bypass graft,” and reduces the influence of radial artery injury on arteriovenous fistula formation, thereby benefiting patients with a potential need for coronary artery bypass grafting and those with chronic renal failure. Third, patients' comfort is significantly improved when adopting dTRA. They can rest their hands in a functional position, which makes them feel comfortable and allows them to better cooperate during the operation. Under right-side dTRA, the hand where the puncture is made can be kept at a resting position during the operation, which is more comfortable to the patients than the palm-up position during radial artery puncture. Under left-side dTRA, patients can place the hand comfortably in the right groin or abdomen with the palm facing down, and the surgeon does not need to lean forward to work on the catheter, which makes the surgeon feel more comfortable and reduces exposure to radiation. Fourth, only the dorsum of the hand needs compression bandage after the operation, while the wrist is not restricted, allowing patients to better tolerate the compression bandage after the operation and to perform daily activities by themselves, such as getting dressed and eating by themselves. Finally, dTRA allows reverse opening of the occluded radial artery[32] or secondary angioplasty for arteriovenous fistula.
Table 1: Advantages and disadvantages of distal transradial artery access compared to transradial artery access

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Disadvantages

dTRA is suitable for most patients; however, in a few patients, dTRA cannot be used because their distal radial artery is too thin or even absent. Compared to TRA, dTRA also has some disadvantages at present [Table 1]. First, dTRA is more challenging in terms of puncture technology, so it requires a longer learning period.[33] Second, by virtue of the emergence of an ultra-thin hydrophilic artery sheath, the diameter of the distal radial artery can be matched with a 7F thin-walled sheath and an 8F sheath-free catheter,[34] but the smaller diameter of the distal radial artery prevents the use of sheaths with a larger lumen; therefore, its application in complex PCI is limited. Third, as the distal radial artery is often more tortuous, the success rate of dTRA is lower than that of TRA.[11] Fourth, compared to TRA, dTRA needs longer puncture time,[28] so surgeons who are not skilled in dTRA should attempt it with caution in the cases of emergency PCI. Fifth, the incidence of puncture pain in dTRA is higher than that in TRA, which is related to swelling and pain in the excessively thin distal radial artery when the puncture needle touches the periosteum or when the sheath is inserted. Finally, because the puncture point in dTRA is located at a further distance, conventional catheters may not be long enough for patients with a height of over 180 cm or with severe dilatation and tortuosity of ascending aorta.


  Choice of Population Top


The superficial location of the distal radial artery is favorable for compression hemostasis, which significantly reduces the postoperative compression time, thereby reducing the probability of occlusion, reducing the incidence of related conventional radial artery complications, and improving patient comfort. It is suggested that surgeons with certain puncture experience can use dTRA as the main choice for PCI. As long as pulse can be palpated in the areas of nasopharyngeal fossa and the Hegu acupoint, a puncture can be attempted. In addition, dTRA is highly recommended in the following situations:

Indicated population

Patients with hematoma or spasm caused by radial artery puncture

Radial artery spasm and hematoma are the common complications of radial artery puncture, especially in females, diabetics, and smokers. If the radial artery cannot be punctured after the occurrence of a complication, distal radial artery puncture can be attempted. By virtue of the bilateral blood supply of the distal radial artery, even if the blood flow in the radial artery is blocked, the pulse of the distal radial artery can be palpated through the deep palmar arch blood flow and puncture and sheath insertion can be performed to complete the procedure.

Patients requiring left transradial artery access for intervention

In patients with CTO, bilateral CAG is necessary for a detailed evaluation of the CTO lesion. If TRA is used in bilateral TRA, most patients cannot tolerate the prolonged adoption of a functional position. With dTRA, patients' hands can be kept in a resting position, which is more comfortable to the patients, while the surgeon can avoid the lumbar flexion position, which is also more comfortable to the surgeon, and can reduce the surgeon's exposure to radiation.[26] In addition, the left dTRA can be adopted when left radial artery puncture is required for a re-evaluation of the left internal mammary artery bypass graft after coronary artery bypass grafting.

Patients with dialysis and renal insufficiency

Arteriovenous fistulation is the artificial establishment of an arteriovenous shunt by vascular surgery technology, which provides long-term and effective extracorporeal circulation vascular access in patients undergoing hemodialysis. Direct anastomosis between the radial artery in the forearm and the cephalic vein is the first choice for patients undergoing hemodialysis. When patients with dialysis and renal insufficiency require PCI, dTRA can more effectively protect the radial artery undergoing fistula formation. In patients with dysfunction of the radial artery–cephalic vein artificial arteriovenous fistula, dTRA is recommended for PCI, which can avoid puncturing, compressing, and other operations on the functional area of fistula. After the operation, the artificial arteriovenous fistula can be immediately used for blood purification.

Patients with radial artery occlusion

Although TRA is more comfortable and convenient for patients, vascular endothelial injury, local hypercoagulable state, and slow blood flow during compression caused by puncture and sheath insertion may lead to radial artery embolism. With the popularization of PCI, the proportion of patients undergoing multiple rounds of PCI through TRA has increased, consequently increasing the risk of radial artery occlusion. In addition, other reasons such as surgery for CTO requiring multiple interventional accesses and patients unable to tolerate femoral artery puncture make it an urgent need to avoid radial artery occlusion. Due to the anatomical structure of the double routes of blood supply to the palm, even if the radial artery is occluded, blood can reach the distal radial artery through the deep palmar arch. After a successful puncture, the radial artery can be opened through this access so that PCI can be completed. When there is early radial artery thrombosis after operation through TRA, if the patient has significant hand symptoms or is at risk of potential dialysis, puncture of dTRA can be attempted for thrombus aspiration and other procedures to open the radial artery.[22] When chronic radial artery occlusion occurs after operation through TRA, the puncture of dTRA can also be attempted for balloon dilatation and other operations to open the radial artery.

Patients with a potential need for coronary artery bypass grafting

When patients requiring coronary artery bypass grafting are relatively young (<50 years), the radial artery is often chosen for coronary artery bypass grafting with complete arterialization. The application of dTRA can reduce the risk of radial artery injury in such patients with a potential need for coronary artery bypass grafting.

Patients with special anatomical structures of the radial artery

The incidence of radial artery tortuosity is as high as 3.8%.[10] In clinical practice, patients with abnormal anatomical structures of the radial artery, such as “dorsally located radial artery” (the radial artery is not in the normal position, with its distal end located on the dorsal side of the wrist joint), are also commonly found. The distal radial artery has a relatively fixed anatomical structure, which makes it easier to achieve a successful puncture.

Geriatric patients undergoing percutaneous coronary intervention

Geriatric patients cannot maintain the same posture for a long time due to limited physical strength, so keeping their arms at a resting position during PCI is favorable for such patients. Furthermore, for geriatric patients, dTRA significantly reduces the incidence of radial artery occlusion and complications such as hematoma.[23]

Contraindicated population

The application value of the Allen test for dTRA is still inconclusive, so the feasibility of dTRA in patients testing positive for the Allen test needs further investigation and confirmation. dTRA cannot be employed in patients with occlusion or absence of the distal radial artery or in those who had already used the radial artery as a bypass graft. In addition, dTRA is not recommended when the body height is over 180 cm or when there is no extended angiographic or guiding catheter so as to avoid operation failure caused by an insufficient catheter length.


  Anatomical Characteristics of the Distal Radial Artery Top


After branching off from the brachial artery, the radial artery courses outward and downward, passing between the brachioradialis and pronator teres muscles and then between the flexor carpi radialis and brachioradialis muscles. It sends out the superficial palmar branch at the styloid process of the radius, which anastomoses with the end of the ulnar artery to form the superficial palmar arch. Then, it continues as the dorsal branch of the radial artery, obliquely crosses the deep surface of abductor hallucis longus and extensor hallucis brevis tendon, turns from the palmar side to the dorsal side of the hand, enters the nasopharyngeal fossa, and goes deep into the palm through the first and second intermetacarpal spaces. After branching out the principal artery of the thumb, it anastomoses with the deep palmar branch of the ulnar artery to form the deep palmar arch [Figure 1].[35],[36]
Figure 1: Anatomical sketch of the radial artery

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The radial artery segment after sending out the superficial palmar branch is known as the distal radial artery. There are two anatomical locations for distal radial artery puncture, namely, the anatomical area of the nasopharyngeal fossa and the area outside the anatomical area of the nasopharyngeal fossa (the Hegu acupoint).[37]

Anatomical area of the snuffbox

The snuffbox is located on the radial side of the wrist and dorsum of the hand. When the thumb is stretched, it resembles a triangular depression with a sharp corner pointing toward the thumb. Its radial boundary is the abductor pollicis longus tendon and extensor pollicis brevis tendon, its ulnar side is the extensor pollicis longus tendon, its proximal boundary is the styloid process of the radius, and its base is the scaphoid and trapezium bones. The pulse of the dorsal carpal branch of the radial artery can be palpated in the fossa [Figure 2].
Figure 2: Anatomical area of the snuff

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Anatomical area of the Hegu acupoint

The Hegu acupoint is located on the dorsum of the hand between the first and second metacarpals and at the radial midpoint of the second metacarpal. The anatomical area of the Hegu acupoint is the area surrounded by the Hegu acupoint, as well as the first and second metacarpals. The dorsal carpal branch of the radial artery crosses the “radial apex” of the first and second metacarpals in this area and branches out the principal artery of the thumb and the radial artery of the index finger outside this area [Figure 3].
Figure 3: Anatomical area of the Hegu acupoint

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Inner diameter of blood vessel

The inner diameter of the radial artery varies from 2.05 ± 0.34 mm to 2.6 ± 0.5 mm in different countries and regions, and the inner diameter of the radial artery is often greater in males than in females.[38] Relatively speaking, there are no large-sample data available on the inner diameter of the distal radial artery. According to some currently available ultrasound measurements performed before and after PCI or intraoperative imaging measurement, the inner diameter of the distal radial artery may vary among different genders and races, ranging from 1.71 ± 0.5 mm to 2.4 ± 0.5 mm. The ratio of the inner diameter of the distal radial artery in the nasopharyngeal fossa area to that in the conventional puncture area is 0.8:1.[37],[39],[40]


  Key Points during Operation Top


Preparation before puncture

Determination of the puncture point

Anatomical localization method

With the patient's wrist inclined to the ulnar side and the thumb abducted, the surgeon palpates the pulse of the radial artery in the anatomical areas of the nasopharyngeal fossa and the Hegu acupoint with the left index and middle fingers and chooses the position with the strongest pulse as the puncture point.[37] If the patient's distal radial artery is difficult to palpate, it suggests that the artery is very thin or deeply located. The “radial apex” at the intersection of the first and second metacarpal bones is suggested to be used as the bony landmark for distal radial artery puncture[34] [Figure 4].
Figure 4: Bony landmark for distal radial artery puncture

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Ultrasonic positioning method

An ultrasonic examination can determine the trending and diameter of the distal radial artery and guide the selection of the puncture point [Figure 5].[40] The examination can be performed before the operation to mark the appropriate internal opening of the puncture point and to guide puncture in real time during operation.[41] Ultrasound-guided dTRA puncture has a higher success rate, so it is the preferred choice for medical institutions where the conditions permit.
Figure 5: Ultrasonic image of the distal radial artery

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Placement of the puncture hand

Puncture of the right hand

The patient adopts the supine position, with the hand in a resting position. The wrist joint is slightly flexed by 10°–15° and inclined to the ulnar side by 10°–30°; the metacarpophalangeal and interphalangeal joints are sem'd, with the flexion angle gradually increasing from the index finger to the little finger and each fingertip pointing the carpal scaphoid tubercle; the thumb is slightly abducted, with the finger pulp approaching or touching the proximal interphalangeal joint of the index finger. The surgeon stands on the patient's right side and performs the puncture.[34] When puncturing, the patient's thumb is held at the center of the palm[9] or a sterile gauze is held in the hand,[34] which makes the anatomical areas of the nasopharyngeal fossa and the Hegu acupoint flatter in order to facilitate puncturing.

Puncture of the left hand

There are two ways to puncture the left hand. First, the patient lies in the supine position, the left hand is placed in the right groin area at a resting position, and the surgeon stands on the right cranial side of the patient to complete the puncture.[9] Second, the patient lies in the supine position with the left hand slightly extended to the left side of the body at a resting position, and the surgeon stands between the patient's trunk and the left hand to complete the puncture.

Preparation of the puncture sheath

The 6F sheath is routinely used for dTRA. Four kinds of puncture sheath introducer kits are currently available in China [Table 2], namely, Braidin® thin-walled sheath introducer kit (APT, Hunan, China), Introducer kit II® sheath introducer kit (Terumo, Tokyo, Japan), Cordis Avanti® sheath introducer kit (Johnson & Johnson, NJ, USA), and Prelude® sheath introducer kit (Merit, UT, USA). Braidin® thin-walled sheath introducer kit has two specifications: a 45-mm-long 22G trocar, a 45-cm-long 0.025” guidewire, a 15-cm-long thin-walled sheath, and a skin incision device and a 40-mm-long 20G bare steel needle, a 45-cm-long 0.025” guidewire, and a 15-cm-long thin-walled sheath. Introducer kit II® sheath introducer kit includes a 32-mm-long 20G trocar, a 45-cm-long 0.025” guidewire, a 16-cm-long sheath, a skin incision device, and a 2.5-mL syringe. Avanti® sheath introducer kit consists of a 40-mm-long 21G bare steel needle, a 45-cm-long 0.021” guidewire, and an 11-mm-long sheath. Prelude® sheath introducer kit includes two specifications: a 40-mm-long 21G bare steel needle, a 40-cm-long 0.018” guidewire, and an 11-cm-long sheath and a 40-mm-long 20G bare steel needle, a 50-cm-long 0.025” guidewire, and an 11-cm-long sheath.
Table 2: Comparison of the parameters of four 6F radial artery sheath introducer kits

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Puncture process

Trocar puncture

Insert the trocar slowly into the anterior wall of the distal radial artery at 30°–45°. After confirming the backflow of blood to the puncture sheath, slightly advance the puncture sheath for approximately 0.5–1 mm, pull out the sheath core, slowly adjust the sheath, fix the sheath with the left hand after blood gushes out, and insert the guidewire into the sheath with the right hand. After puncturing the skin, insert the radial artery sheath along the guidewire. In case resistance is encountered, the sheath can be slowly rotated and advanced. As the distal radial artery is close to the scaphoid and trapezoid bones, it can easily cause severe pain when the puncture needle touches the periosteum. Therefore, it is recommended not to penetrate the posterior wall of the artery as far as possible.[9] At this time, the sheath can be pushed forward along the puncture needle core, and the needle core can then be withdrawn.

Open steel needle puncture

Insert the open puncture steel needle slowly into the anterior wall of the radial artery at 15°–30°. After confirming blood gushing or dripping from the puncture needle, fix the puncture needle with the left hand and advance the guidewire into the sheath with the right hand.[24] After puncturing the skin, insert the radial artery sheath along the guidewire. In case of encountering resistance, the sheath can be slowly rotated and advanced. Application of the improved Seldinger puncture method that does not penetrate the posterior wall of the blood vessel has been recommended so as to minimize pain for patients.[9]

Common reasons for failure and countermeasures

The success rate of dTRA has been reported to be 70%–100%.[10],[11],[12],[24],[26],[27],[28],[29],[33],[36],[37],[40],[41],[42],[43],[44],[45],[46],[47] After dTRA fails, it can be switched to ipsilateral TRA or contralateral dTRA or TRA, and if bilateral radial arteries are occluded, it can be switched to transfemoral artery access.[11] After puncture of the distal radial artery fails, even if there is no bleeding at the puncture point, bleeding and hematoma might occur after the operation. It is recommended to manually compress for hemostasis for 5–10 min before changing the arterial access and apply compression bandage to the puncture point after the operation.

The main reason for dTRA failure is that the artery cannot be punctured, or if at all it can be punctured, the guidewire cannot be delivered smoothly; this failure to deliver the guidewire occurs very frequently[24] and occurs because of occlusion of the radial artery, guidewire entering the ulnar side of the deep palmar arch, natural bending of the distal radial artery from the palmar side to the dorsal side, and tortuosity of the radial artery. Radial artery occlusion can be checked by palpating the radial artery pulsation or performing ultrasound before the operation. Puncturing the nasopharyngeal fossa area or delivering the guidewire under fluoroscopic guidance can avoid entering the ulnar side of the deep palmar arch. If it is difficult to pass the guidewire through the natural bending of the distal radial artery or the tortuous radial artery, the guidewire can be withdrawn and a 3–5 mm segment at its head end can be bent by 30°–45°; in case of resistance, the guidewire can be slightly withdrawn, slowly rotated clockwise by 30°, and then delivered again with repeated attempts.[9] Alternatively, a 0.014” PTCA guidewire can be delivered by clockwise rotation; then, the punctured trocar should be inserted along the guidewire and replaced with the punctured guidewire,[33] or the sheath can be gently advanced along the PTCA guidewire (there is a risk of failure, so it is recommended to try slowly under fluoroscopic guidance).

Postoperative compression hemostasis and nursing

Elastic/adhesive bandage

At present, compression hemostasis is mostly performed with elastic or adhesive bandages in China. After completing CAG or PCI, fold a piece of gauze in half thrice and place it at the puncture point. Keep the long axis of the gauze parallel to the distal radial artery and the one-third intersection point between the front and middle segments of the gauze, coinciding with the puncture point. Remove the arterial sheath and wrap the hand for 3–5 circles or by “figure 8” wrapping for 4–5 circles with an elastic bandage for fixation, or use three adhesive tapes for “figure 8” wrapping for sticking fixation [Figure 6]. According to the heparin dose, remove the bandage after 2–6 h.
Figure 6: Bandaging methods. Wrapping with an elastic bandage for three circles for fixation (a); Cross-wrapping with an elastic bandage for fixation (b); Using three adhesive tapes for cross-wrapping for sticking fixation (c)

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Hemostatic device compression

After removing the plastic plate, Terumo radial artery hemostatic device can be used for compression hemostasis, and the hemostatic device can be removed 60–90 min after CAG and 90–120 min after PCI.[28] Alternatively, the distal radial artery hemostatic device SafeGuard® or PreludeSYNC™ can be used for compression hemostasis, which can be removed after 2–3 h.[9],[42] At present, no distal radial artery hemostatic device has been developed for clinical application in China, and APT Medical Inc. has designed a new-generation distal radial artery hemostatic device, which will enter clinical application soon.

Manual compression

Under special circumstances, manual compression of the puncture point can also be adopted for hemostasis after the operation, with a compression time of 10–20 min.[29] However, evidence-based medicine support is limited at present, so it is not recommended to use this compression method routinely.

Complications and treatment

The complications of dTRA mainly include hematoma, radial artery occlusion, pain and finger numbness, pseudoaneurysm, and arteriovenous fistula.[10],[11],[12],[24],[26],[28],[29],[33],[36],[37],[40],[41],[42],[43],[44],[45],[46],[47] The incidence of hematoma ranges from 0% to 14.3%, but there is no report on osteofascial compartment syndrome. Radial artery occlusion caused by distal radial artery puncture is mostly distal radial artery occlusion, with an incidence of 0%–5%, and proximal radial artery occlusion is extremely rare, with an incidence of 0%–0.9%. The blood vessels feeding the carpal bones, such as the scaphoid bone, mostly originate from the distal radial artery, so there is potential for damage. In addition, the superficial branch of the radial nerve often accompanies the distal radial artery, and its injury may cause finger numbness, with an incidence of 0%–5.9%. Pseudoaneurysm and arteriovenous fistula are rarely caused by distal radial artery puncture. A pseudoaneurysm may disappear upon ultrasound-guided compression for 10 min or elastic bandage compression for 2 h.[48] In the case of arteriovenous fistula, the compression time by a hemostatic device can be prolonged to close the fistula.[28] If it cannot be closed, surgical treatment is required.[43] Due to the short time since the emergence of the dTRA technique, its long-term complications require further observation and investigation.


  Conclusion Top


dTRA can improve patients' comfort during operation, significantly reduce the time of hemostasis and incidence of complications after the operation, and be used to open the occluded arteriovenous fistula and radial artery. Thus, this procedure makes up for some of the shortcomings of TRA and is becoming a new attempt of PCI. However, dTRA still has certain shortcomings, such as the potential impact on the distal radial artery and relatively long learning period. Therefore, the education and training of young surgeons should be continuously strengthened to promote the clinical application of dTRA more widely. With the continuous development of interventional technology, the innovation of equipment, and more evidence-based medicine support, dTRA will continuously develop, thereby effectively improving the comfort and precision of PCI.

Expert group leaders: Jun-Bo Ge (Zhongshan Hospital Affiliated to Fudan University), Ji-Yan Chen (Guangdong Provincial People's Hospital), Jiong-Ren Wu (Kaohsiung Chang Gung Memorial Hospital, Taiwan), Shu-Bin Qiao (Fuwai Hospital of Chinese Academy of Medical Sciences), Yong Huo (Peking University First Hospital)

Drafting group members: Shu-Wei Huang (Xinhua Hospital of Zhejiang Province), Kun-Qing Song (Cangzhou Central Hospital), Xin Sun (Shenzhen People's Hospital), Neng Wang (Suizhou Hospital Affiliated to Hubei University of Medicine), Feng Zhang (Zhongshan Hospital Affiliated to Fudan University)

Expert group members (sorted by the first letter of surname): An-Yong Chen (Affiliated Hospital of Jining Medical University), Ji-Shun Chen (Sinopharm Dongfeng General Hospital), Ji-Yan Chen (Guangdong Provincial People's Hospital), Kang Cheng (Xi'an No. 3 Hospital), Shu-Jie Chen (Handan Central Hospital), Yun-Dai Chen (Chinese PLA General Hospital), Ye Cheng (Xiamen Cardiovascular Hospital Affiliated to Xiamen University), Ke-Fei Dou (Fuwai Hospital of Chinese Academy of Medical Sciences), Shao-Hong Dong (Shenzhen People's Hospital), Yong Dong (Zhengzhou Cardiovascular Hospital), Guo-Sheng Fu (Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine), Jun-Bo Ge (Zhongshan Hospital Affiliated to Fudan University), Li-Jian Gao (Fuwai Hospital of Chinese Academy of Medical Sciences), Jiang-Tao Hou (Chinese University of Hong Kong Medical Centre), Shu-Wei Huang (Xinhua Hospital of Zhejiang Province), Yong He (West China Hospital of Sichuan University), Yong Huo (Peking University First Hospital), Quan-Min Jing (General Hospital of Northern Theater Command), Zhi-Tao Jin (Beijing PLA Rocket General Hospital), Gang Li (Sichuan Provincial People's Hospital), Hong-Mei Li (Cangzhou Central Hospital), Jian-Fang Luo (Guangdong Provincial People's Hospital), Lin-Jie Luo (Shenzhen People's Hospital), Jian-Ping Li (Peking University First Hospital), Jing-Qian Lu (The First Hospital of Kunming), Xiao-Lan Li (Xiangyang No.1 People's Hospital), Xi-Ming Li (Tianjin Chest Hospital), Yan Li (Tang Dou Hospital of Air Force Military Medical University), Yong-Jun Li (The Second Hospital of Hebei Medical University), Yu-Ming Lu (Guiyang First Hospital), Hua-Dong Liu (Shenzhen People's Hospital), Ying-Wu Liu (Tianjin Third Central Hospital), Peng Qu (The Second Hospital of Dalian Medical University), Shu-Bin Qiao (Fuwai Hospital of Chinese Academy of Medical Sciences), Lei-Sheng Ru (Bethune International Peace Hospital), Kun-Qing Song (Cangzhou Central Hospital), Xin Sun (Shenzhen People's Hospital), Chang-Lu Wang (Hunan Provincial People's Hospital), Hui Wang (Tianjin Third Central Hospital), Jiong-Ren Wu (Kaohsiung Chang Gung Memorial Hospital, Taiwan), Neng Wang (Suizhou Hospital Affiliated to Hubei University of Medicine), Ren-Rong Wang (Wuxi Second People's Hospital), Shen Wang (Xinhua Hospital of Zhejiang Province), Ze-Sheng Xu (Cangzhou Central Hospital), Wei Yao (Suizhou Hospital Affiliated to Hubei University of Medicine), Xi Yang (Guiyang First Hospital), Xun-Long Ye (Sijhih Cathay General Hospital, Taiwan), Chang-Lin Zhang (The Second Hospital of Dalian Medical University), Feng Zhang (Zhongshan Hospital Affiliated to Fudan University), Jun Zhang (Cangzhou Central Hospital), Chuan-Shou Zhang (Shenzhen People's Hospital), Yu-Jie Zhou (Beijing Anzhen Hospital).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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