Comparison of Success Rate Between Distal Radial Approach and Radial Approach in STEMI

Comparison of Success Rate Between Distal Radial Approach and Radial Approach in ST-segment Elevation Myocardial Infarction

ST-segment elevation myocardial infarction (STEMI) is an emergent disease to treat as soon as possible. 2017 ESC guidelines for the management of STEMI recommend using radial approach (RA) rather than femoral approach (FA) to reduce mortality and bleeding complications if the operators are expert for RA. Recently, Ferdinand Kiemeneij reported that distal radial approach (DRA) could be a feasible and safe route for coronary angiography (CAG) and percutaneous coronary intervention (PCI) in 70 patients. The right-handed patient could feel more comfortable in left DRA than right RA. Left DRA also could provide a better comfortable position for the operator compared to left RA. Distal radial artery is located around the anatomical snuffbox, which doesn't contain nerve and vein beside artery. Therefore, the possibility of procedure-related complications such as nerve injury or arteriovenous fistula is very low. Also, the superficial location of DRA could make easier hemostasis. There were no vascular-related complications from the report of Kiemeneij. But, the rate of puncture failure was 11%, which was higher than RA-based study (5.34% in STEMI patients of RIVAL trial, 6% in RIFLESTEACS trial and 5.8% in MATRIX trial). Nevertheless, this study was a pilot study with a small number of patients. There is no clinical study to compare the feasibility and safety for CAG and PCI between DRA and RA in patients with STEMI. Therefore, this study aimed to evaluate whether DRA is feasible and safe compared to RA in STEMI setting.

After subcutaneous injection of lidocaine, the distal radial artery around the bony surface area is punctured with a 20-gauge venipuncture catheter needle or steel needle according to the operator's discretion. After successful puncture, flexible, straight plastic 0.025" mini-guidewire is inserted through the hole of the puncture needle. Then, Radifocus® introducer sheath (Terumo, Tokyo, Japan) is inserted into the distal radial artery.

After subcutaneous injection of lidocaine, the radial artery is punctured with a 20-gauge venipuncture catheter needle or steel needle according to the operator's discretion. After successful puncture, flexible, straight plastic 0.025" mini-guidewire is inserted through the hole of the puncture needle. Then, Radifocus® introducer sheath (Terumo, Tokyo, Japan) is inserted into the radial artery.

The distal radial artery will be punctured with a puncture needle. Then, coronary angiography and percutaneous coronary intervention will be performed.

The radial artery will be punctured with a puncture needle. Then, coronary angiography and percutaneous coronary intervention will be performed.

The success rate (%) of arterial puncture will be compared between distal radial artery approach and radial artery approach group.

The success rate (%) of coronary angiography will be compared between distal radial artery approach and radial artery approach group.

The success rate (%) of percutaneous coronary intervention will be compared between distal radial artery approach and radial artery approach group.

The success rate (%) of final procedure will be compared between distal radial artery approach and radial artery approach group.

The bleeding complication rate (%) will be compared between distal radial artery approach and radial artery approach group.

Scale range: 0 - 360 minutes Shorter time is associated with better outcome. An averaged time value will be compared and reported between two groups.

Scale range: 0 - 360 minutes Shorter time is associated with better outcome. An averaged time value will be compared and reported between two groups.

Scale range: 0 - 500 Gray/cm2 Lesser fluoroscopic dose is better. An averaged value will be compared and reported between two groups.

Incidence rate (%) of composite endpoints defined as all-cause death, any myocardial infarction, stroke and major bleeding

Scale range: 0 - 60 minutes Shorter time is considered better result. An averaged time value will be compared and reported between two groups.

Inclusion Criteria: Age ≥ 20 years ST-segment elevation myocardial infarction Palpable unilateral distal radial and radial artery Exclusion Criteria: Cardiogenic shock Thrombolysis before primary percutaneous coronary intervention Inability to obtain written informed consent Patient with ipsilateral arteriovenous fistula Participation in another ongoing clinical trial Pregnancy Expected lifespan <12 months * Eligible operator criteria Qualified operator who had experienced ≥ 100 cases of distal radial artery puncture