Discussion
The access of the dTRA in the anatomical snuffbox was initially
described with the objective of recanalization of occluded retrograde
radial arteries [13,14], being proposed as an alternative route of
arterial access, aiming to preserve the radial artery and for possible
surgical procedures. In 2017, Kiemeneij [13] arouses scientific
curiosity with the publication of a series of 70 patients in which
diagnostic catheterization or coronary intervention was performed by
left distal transradial puncture (ldTRA). Although there were 8 puncture
failures (11.4%), the remaining 62 patients did not impose major
difficulties or report significant discomfort during the exam.
In the Babunashvili and Dundua series of 637 patients with radial
access, 9 the anatomical snuffbox was used in 92%, only 11% were PCI
procedures and the sheath size was 5 F in 91% and 6 F in 9%. The
overall success rate was 98%. Radial artery occlusion rate was 0%
acute and 0.2% late (more than 3 months) follow-up [11].
In addition, a study published by Kaledin et al. [12] presented
2,884 patients undergoing endovascular surgery interventions, 10 the
anatomical snuffbox was used in 96% of the patients, 93.5% of the
interventions were PCI procedures, with a 6F sheath in 98% and 7F in
1%. The success rate was 97%. In the follow-up, the rate of occlusion
of the radial artery at the access site with preserved blood flow from
the radial artery of the forearm was observed in 2% cases; occlusion of
the radial artery of the forearm after catheterization of the artery
inside the anatomical snuffbox was observed in 0.4% of cases. This
contrasts with the rate of occlusion of the radial artery of 4.2%
observed by the same authors, using the traditional radial approach of
the forearm. Other complications at the access site were similar to
those observed with the forearm approach: hematoma (0.2%), pulsatile
hematoma (<0.1%), infection (0.1%), dissection (0.1%),
fistula arteriovenous (<0.1%).
In addition, in the work of Roghani-Dehkordi et al. [15], a series
of 235 patients with access to the anatomical snuffbox, 13 29% were PCI
procedures. The success rate was 94%, the rate of asymptomatic radial
artery occlusion at the site of access was about 1%. In addition, of
the 118 consecutive patients assigned to the Kiemeneij operation
program, 70 patients (40.7%) were considered suitable for ldTRA access.
There were eight procedural flaws, requiring crossover to traditional
right radial or left radial approach. All other procedures were
successful (89%), without great discomfort for the patient and
operator. No occlusion of the radial artery at the forearm site was
found.
Thus, according to these literary findings, Table 3 below
presents the main considerations and advantages of dTRA and ldTRA.
Table 3. Importance of the distal and left radial
approach.