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.