This document describes a novel "snuff-box technique" for transradial catheterization using a distal puncture of the radial artery. The author hypothesizes that distal puncture may reduce rates of radial artery occlusion (RAO) and bleeding complications compared to traditional puncture sites. Data from 637 patients found lower RAO rates and complication risks with distal versus traditional access. A future randomized trial is proposed to further evaluate distal access versus traditional sites.

1. NOVEL SNUFF-BOX TECHNIQUE FOR
TRANSRADIAL APPROACH: LET’S GO
DISTAL
Avtandil M. Babunashvili
Center of Endosurgery, Moscow, Russia

2. Disclosure: Avtandil M. Babunashvili, MD
I have no conflict of interests to disclose

3. Background:
_______________________________________________
Transradial interventions (TRI) are associated with a certain risk of radial
artery occlusion, limiting the possibility of re-intervention through the
same access site.
RAO was detected in 95 cases (4.5%) out of 2073 repeat transradial
interventions for diagnostic and interventional procedures from
January 2005 to September 2014.

4. hypothesis:
Distal RA puncture and cannulation may lessen
RAO rate and bleeding complications

5. COMPARISON OF RADIAL ARTERY ENTRY POINTS
Mean diameter ± SD, mm
Radial artery 2,27 ± 0,35
Distal puncture area 1,99 ± 0,29

6. Anatomy of the radial artery
Os scaphoid
Os trapezium

7. Traditional
puncture point
Os scaphoid
Os trapezium

8. RAO RECANALIZATION THROUGH THE DISTAL ENTRY POINT

11. Distal arterial circulation – without embolization

12. N = 637 patients
male
Access parameters
Mean
diameter
Type of procedure Sheath size
Puncture
time
Right
RA
success
ful
PCI diagnostic success
ful
5F 6F
Snuffbox
(n=54)
17 16,8 ±
7,23sec
52 50 - 14 36 100% 39 11
Distal RA
(n=583)
417 14,5 ±
8,71sec
573 573 1,99 ±
0,29 mm
53 520 100% 529 44
434
(68,1%)
- 625
(98,1%)
623
(97,8%)
14 – c/o
- 67
(10,7%)
556
(89,3%)
100% 568
(91,2%)
55
(8,8%)
0
1
2
0-50 50-100 100-200 200-300 300-400 >400
Number of attempts
0
20
40
0-50 50-100 100-200 200-300 300-400 >400
Puncture time, sec
DISTAL RADIAL ENTRY POINT FOR TRI AS THE PRIMARY ACCESS POINT FOR ROUTINE PRACTICE

13. Snuffbox access
Distal RA access
DISTAL RADIAL ENTRY POINT FOR TRI AS THE PRIMARY ACCESS POINT FOR ROUTINE PRACTICE

14. IMMEDIATE RESULTS FOLLOW UP
(>3 MONTHS)
(n=195: snuffbox
=48, distal = 147)
bleeding hematoma Acute RA
thrombosis (0-24h)
Spasm/
Discomfort
or pain
Late
RAO
Other vascular
complications
Snuffbox
(n=50)
0 4 (8,0%) 0 5 (10%) 1
(2,0%)
0
Distal RA
(n=573)
0 4 (0,7%) 0 21 (3,6%) 0 0
DISTAL RADIAL ENTRY POINT FOR TRI AS THE PRIMARY ACCESS POINT FOR ROUTINE PRACTICE

15. Comparison between Traditional ENtry point and Distal puncturE of Radial Artery
(TENDERA STUDY)
Patients referred for elective coronary
diagnostic or interventional procedure
1:1 randomization
RA access in
forearm part
Distal RA access
1 week 1 month 6 months 12 months
US examination
Primary end point: Radial artery occlusion
Secondary end point: Bleeding (2-3 BARC), Hematoma (>5cm), ASRVC
Estimated Sample size: 830 patients
Start date: IVQ 2015, End date: IVQ 2018
• Age <75
• Primary puncture
• RA dia >1,5mm
• Sheath needed 5-6F
• Stable IHD
• Height <185cm

16. Hemostasis

17. Hemostasis
US confirmation of
radial artery patency
during compression
bandage hemostasis

18. Hemostasis
Continuous blood flow in forearm part
of Radial artery

19. Hemostasis
 Reliable compression hemostasis thanks to “surrounding anatomy”
 No venous stasis because of absence of major forearm venous
compression
 Radial artery blood flow does not get blocked despite compression of
distal puncture point
 No discomfort (pain etc) and hand dysfunction related to
compression bandage

20.  Lack of dedicated hemostasis devices
 Length of catheters for tall patients
 Smaller diameter than in the traditional access point
Limitations of the distal RA access

21. CONCLUSION
 Distal radial artery access is reliable, safe, effective and is
well-suited for all kinds of coronary intervention procedures,
to the traditional radial artery entry point
 Distal RA access may be associated with less RAO rate, bleeding and
vascular access site related complications in comparison with traditional
RA access
 More data is needed to establish new radial artery access in routine
clinical practice