The radial artery has become the standard vascular access site for most percutaneous
coronary interventions (PCI) and is recommended by the most recent 2018 European Society
of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on myocardial
revascularization, irrespective of clinical presentation. Patients undergoing PCI of
complex coronary lesions, such as a chronic total occlusion (CTO), left main (LM)
coronary artery disease, complex bifurcation lesions, or heavily calcified lesions, have
however been either absent or under-represented in most trials supporting these
guidelines.
The small size of the radial artery remains an important limitation for the use of large
bore guiding catheters (>6 F), restricting thereby the treatment of highly complex
lesions through the transradial approach. The 7F GLIDESHEATH SLENDER® (Terumo Corp.,
Tokyo, Japan) is a dedicated radial sheath with a thinner wall and hydrophilic coating.
It combines an inner diameter compatible with any 7F guiding catheter and an outer
diameter smaller than current 7F sheaths.
A prospective, multicenter, observational study including 60 patients demonstrates that a
transradial access (TRA) using the 7F GLIDESHEATH SLENDER® (Terumo Corp., Tokyo, Japan)
for complex coronary interventions is feasible and associated with a high rate of
procedural success and a low rate of vascular complications.
In the Complex Large-Bore Radial Percutaneous Coronary Intervention (COLOR) randomized
trial, 388 patients with planned PCI for complex coronary lesions were randomly allocated
to a 7F TRA or 7F transfemoral access (TFA). Conventional TRA was associated with a
significant reduction in clinically relevant access- site bleeding or vascular
complications without affecting procedural success when compared to TFA among patients
undergoing complex PCI with a 7F large bore access.
The use of the distal radial artery has recently emerged as a promising alternative
access route to further reduce the risk of radial artery occlusion (RAO) and has been
endorsed by recent International Consensus documents. The feasibility of a distal radial
access (DRA) for coronary angiography and/or PCI has been demonstrated in several
observational clinical registries and small-sized randomized clinical trials. In the
recent prospective, multicenter, open label, randomized, controlled DIStal vs
Conventional RADIAL access (DISCO RADIAL) trial, DRA was associated with low and similar
rates of RAO at discharge when compared to conventional TRA among patients undergoing
coronary angiography and/or PCI. There is however limited evidence on the feasibility and
safety of 7F DRA for PCI. The potential advantages of DRA when compared to TRA are
contrasted by a slightly smaller size of the distal radial artery potentially impacting
on device selection and procedural planning and by its less predictable course, due to
the pronounced tortuosity and angulation of the vessel, leading to an overall higher
number of puncture attempts, a longer time to achieve arterial access and a higher rate
of access failure. These limitations may preclude the use of DRA for PCI of complex
coronary lesions when a large bore guiding catheter is needed. There is however limited
evidence on the feasibility and safety of 7F DRA for PCI.
In a prospective, multicenter, observational study including 41 patients undergoing CTO
PCI using a left DRA with a 7F GLIDESHEATH SLENDER® (Terumo Corp., Tokyo, Japan),
technical success was achieved in 90.3% of patients and procedural success was achieved
in 78.1% of patients. No post-procedural DRA RAO were detected by clinical assessment and
Doppler ultrasound examination, and no radial artery occlusions at the site of the
forearm were found. Doppler ultrasound imaging of the DRA at one month was available in
67.6% of patients, with only one case (4.3%) of DRA RAO. This proof-of-concept study
demonstrates that DRA using a 7F GLIDESHEATH SLENDER® (Terumo Corp., Tokyo, Japan) for
CTO PCI is feasible and associated with a high procedural success rate and low vascular
access-site complication rates.
No randomized clinical trial to date has however compared the feasibility and safety of a
7F DRA versus 7F TRA for PCI of complex coronary lesions, such as chronic total
occlusions (CTO), left main coronary artery disease, heavily calcified lesions, complex
bifurcations, or other complex coronary lesions for whom the operator anticipates that a
7F guiding catheter is indicated.