Pulse-dependent association of ultrasound guidance with distal radial access success

Background: Ultrasound (US)-guided puncture has been proposed to improve distal radial access (DRA), although its benefit may vary according to anatomical and clinical factors.Aims: To evaluate whether the association between US-guided puncture and DRA success varies according to the pulse strength of the distal radial artery.Methods: We analyzed 1454 consecutive DRA procedures from the multicenter DISTAL Registry (August 2020-November 2024).Pulse grades were combined as absent or weak (0-1) and normal or strong (2-3).The primary outcome was DRA success.Multivariable logistic regression with interaction testing and a 2-stratum Mantel-Haenszel sensitivity analysis were used.Results: Overall success was 96.8% and was similar with and without US guidance (97.3% vs. 95.7%;P = 0.14).US guidance was associated with higher success in grades 0-1 (adjusted odds ratio [OR], 11.20; 95% confidence interval [CI], 3.97-31.61;P <0.001), but not in grades 2-3 (adjusted OR, 1.06; 95% CI, 0.33-3.38;P = 0.92; interaction P <0.001).The Mantel-Haenszel sensitivity analysis yielded an OR of 2.62 (95% CI, 1.46-4.71;P <0.001), with significant heterogeneity.Access time was shorter with US guidance in patients with weak pulse. Conclusions:The association between US guidance and DRA success was pulse-dependent, with higher success in the combined absent or weak category but not in the normal or strong category.Access time was also shorter with US guidance, most markedly in patients with a weak pulse.A pulse-guided strategy may optimize US use in DRA.