Distal Transradial Artery Access for Neuroangiography and Neurointerventions: Pitfalls and Exploring the Boundaries

INTRODUCTION: The distal transradial approach (dTRA) is progressively gaining more clinical use in the fields of cardiology and other vascular interventions, as it offers a number of advantages compared to conventional radial approach (TRA). These include lower rates of vascular occlusion which permits preservation of the proximal radial artery for future procedures in the event of a distal occlusion. AIM: To share the experience in the use of dTRA for neurointerventions, showing its advantages, pitfalls as well as sharing our optimized puncture and hemostatic ultrarapid compression protocols to improve the use of this vascular access. METHODS: A retrospective analysis of our experience of diagnostic and interventional procedures performed via dTRA using an optimized protocol for puncture and postpuncture compression of the dTRA was performed. The rate of complications (hematoma and arterial dissection at puncture site) femoral crossover, and assessment of postprocedural stenosis/occlusion with the ultrarapid compression protocol were also assessed. RESULTS: From March 2019 to July 2020 a total of 100 distal radial procedures were carried out and 53 diagnostic angiograms (53%) and 47 interventional procedures (47%) were included in the analysis. We achieved a 96% technical success, with a femoral crossover requirement in 3 cases (3%), and one conventional TRA crossover due to puncture failure. Of the patients 3 presented puncture site hematomas (3%) with no intervention required, 61 patients (61%) underwent the ultrarapid hemostasis protocol in association with a hemostatic pad. Ultrasound follow-up was performed in 20 patients (20%) at 1–2 months with 1 case of occlusion (5%) and 2 of radial stenosis (10%). In all 3 cases proximal radial artery remained patent. CONCLUSION: The dTRA is a safe and feasible access route for angiography and neurointerventions. Using vasodilators prepuncture, we attained a variable increase in the vascular diameter facilitating puncture and reducing the risk of occlusion and vascular spasm. A rapid deflation protocol for postpuncture hemostasis does not significantly increase the hematoma rate.