Achim Alexandru, Szigethy Tímea, Olajos Dorottya, Molnár Levente, Papp Roland, Bárczi György, Kákonyi Kornél, Édes István F, Becker Dávid, Merkely Béla, Van den Eynde Jef, Ruzsa Zoltán
Division of Invasive Cardiology, Internal Medicine Department, University of Szeged, Szeged, Hungary.
"Niculae Stancioiu" Heart Institute, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania.
Front Cardiovasc Med. 2022 May 9;9:895457. doi: 10.3389/fcvm.2022.895457. eCollection 2022.
Distal radial access (DRA) was recently introduced in the hopes of improving patient comfort by allowing the hand to rest in a more ergonomic position throughout percutaneous coronary interventions (PCI), and potentially to further reduce the rate of complications (mainly radial artery occlusion, [RAO]). Its safety and feasibility in chronic total occlusion (CTO) PCI have not been thoroughly explored, although the role of DRA could be even more valuable in these procedures.
From 2016 to 2021, all patients who underwent CTO PCI in 3 Hungarian centers were included, divided into 2 groups: one receiving proximal radial access (PRA) and another DRA. The primary endpoints were the procedural and clinical success and vascular access-related complications. The secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and procedural characteristics (volume of contrast, fluoroscopy time, radiation dose, procedure time, hospitalization time).
A total of 337 consecutive patients (mean age 64.6 ± 9.92 years, 72.4% male) were enrolled (PRA = 257, DRA = 80). When compared with DRA, the PRA group had a higher prevalence of smoking (53.8% vs. 25.7%, SMD = 0.643), family history of cardiovascular disease (35.0% vs. 15.2%, SMD = 0.553), and dyslipidemia (95.0% vs. 72.8%, SMD = 0.500). The complexity of the CTOs was slightly higher in the DRA group, with higher degrees of calcification and tortuosity (both SMD >0.250), more bifurcation lesions (45.0% vs. 13.2%, SMD = 0.938), more blunt entries (67.5% vs. 47.1%, SMD = 0.409). Contrast volumes (median 120 ml vs. 146 ml, = 0.045) and dose area product (median 928 mGy×cm vs. 1,300 mGy×cm, < 0.001) were lower in the DRA group. Numerically, local vascular complications were more common in the PRA group, although these did not meet statistical significance (RAO: 2.72% vs. 1.25%, = 0.450; large hematoma: 0.72% vs. 0%, = 1.000). Hospitalization duration was similar (2.5 vs. 3.0 days, = 0.4). The procedural and clinical success rates were comparable through DRA vs. PRA ( = 0.6), moreover, the 12-months rate of MACCE was similar across the 2 groups (9.09% vs. 18.2%, = 0.35).
Using DRA for complex CTO interventions is safe, feasible, lowers radiation dose and makes dual radial access more achievable. At the same time, there was no signal of increased risk of periprocedural or long-term adverse outcomes.
最近引入了桡动脉远端入路（DRA），希望通过在整个经皮冠状动脉介入治疗（PCI）过程中让手部处于更符合人体工程学的位置来提高患者舒适度，并有可能进一步降低并发症发生率（主要是桡动脉闭塞，[RAO]）。尽管DRA在这些手术中的作用可能更有价值，但其在慢性完全闭塞（CTO）PCI中的安全性和可行性尚未得到充分探索。
纳入2016年至2021年在匈牙利3个中心接受CTO PCI的所有患者，分为2组：一组接受桡动脉近端入路（PRA），另一组接受DRA。主要终点是手术和临床成功率以及血管入路相关并发症。次要终点是主要不良心脑血管事件（MACCE）和手术特征（造影剂用量、透视时间、辐射剂量、手术时间、住院时间）。
共纳入337例连续患者（平均年龄64.6±9.92岁，72.4%为男性）（PRA组 = 257例，DRA组 = 80例）。与DRA组相比，PRA组吸烟患病率更高（53.8%对25.7%，标准化均值差[SMD] = 0.643）、心血管疾病家族史患病率更高（35.0%对15.2%，SMD = 0.553）以及血脂异常患病率更高（95.0%对72.8%，SMD = 0.500）。DRA组CTO的复杂性略高，钙化和迂曲程度更高（均SMD>0.250），分叉病变更多（45.0%对13.2%，SMD = 0.938），钝端入口更多（67.5%对47.1%，SMD = 0.409）。DRA组的造影剂用量（中位数120 ml对146 ml，P = 0.045）和剂量面积乘积（中位数928 mGy×cm对1300 mGy×cm，P < 0.001）更低。从数字上看，PRA组局部血管并发症更常见，尽管这些未达到统计学意义（RAO：2.72%对1.25%，P = 0.450；大血肿：0.72%对0%，P = 1.000）。住院时间相似（2.5天对3.0天，P = 0.4）。通过DRA与PRA的手术和临床成功率相当（P = 0.6），此外，两组的12个月MACCE发生率相似（9.09%对18.2%，P = 0.35）。
在复杂CTO干预中使用DRA是安全、可行的，可降低辐射剂量并使双侧桡动脉入路更易实现。同时，没有围手术期或长期不良结局风险增加的迹象。
