Distal radial access in interventional cardiology: technique, pitfalls and recommendations

Figure 1. Image of the left hand and its relationship to the radial artery and visible anatomical structures associated with distal radial access. The puncture sites used in the distal radial access are highlighted, in the area of the AS (yellow arrow) and in the dorsal area, distal to the extensor pollicis longus tendon (white arrow), which forms the medial side of the AS (triangle with dotted lines). AS, anatomical snuffbox; CV, cephalic vein; DPA, deep palmar arch; DRart, distal radial artery; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; PRart, proximal radial artery; SPA, superficial palmar arch.

Figure 2. Anatomy of the distal radial artery by Doppler ultrasound. White arrow, proximal radial artery; yellow arrows, distal radial artery. APL, abductor pollicis longus tendon; CV, cephalic vein; EPB, extensor pollicis brevis tendon; EPL, extensor pollicis longus tendon; MB, metacarpal bones; RB, radial bone; RN, radial nerve; SB, scaphoid bone; TB, trapezium bone.

Video 1. Ultrasound evaluation of the hand from the deep palmar arch to the distal radial artery as it passes over the trapezium and scaphoid, common puncture sites for distal radial access.

Video 2. Ultrasound evaluation of the proximal radial artery from the wrist to its junction with the brachial artery.

Figure 3. Position of the patient in the distal radial access left and right. (A) Position of the right hand for puncture, resting on a gauze package, where hyperextension of the wrist is observed. (B,C) Right-hand position supported with the designed arm board, with which the position is more precise. (D) Final position of the right hand once the sterile drape is in place. (E,F) The left hand positioned for puncture, using the usual technique (E) and supported by the designed arm board (F), with which the position is more precise and the comfort is greater for the patient. (G) Final position of the left hand after placing the sterile drape, highlighting that the hole used is the one corresponding to the left femoral access, for better organization of the work area.

Figure 4. Equipment used for ultrasound-guided distal radial artery cannulation and sheath insertion. (A) Setup for the DRA puncture, including US probe, introducer sheath, 21-G needle, micro guidewire, and local anesthesia. (B,C) Comparison of the sheaths and needles of the Prelude [1] and Radifocus [2] introducers. (D) Different guidewires used for the distal radial access, spring-coiled wire (white arrow) and stainless-steel wire (yellow arrow). DRA, distal radial access; US, ultrasound.

Video 3. Ultrasound-guided puncture of the distal radial artery, showing the tenting of the needle as it crosses the distal radial artery in a cross-sectional view.

Figure 5. Puncture technique blind by palpation (left) and ultrasound-guided (right). (A,B) Application of anesthesia with both techniques. (C,D) Palpation and ultrasound-guided puncture of the distal radial artery. (E) Sharp needle angulation and rotation on its own axis for correct guidewire advance. (F) Final position of the introducer sheath in the anatomical snuffbox.

Video 4. Aliasing artifact observed during color Doppler ultrasound-guided arterial puncture.

Figure 6. Alternative technique for ultrasound-guided arterial puncture. From top to bottom, progressive angulation of the ultrasound probe on its own axis (left), the course of the needle (right, arrows) from the most superficial to contact with the distal radial artery and the tenting observed during its puncture are observed.

Figure 7. Fluoroscopic and ultrasound guidance verification. (A) Dorsal puncture in which the guidewire has advanced to a metacarpal branch. (B) Puncture in the anatomical snuffbox of the same patient in whom the guide wire has corrected its course towards the proximal radial artery. (C,D) Cross-sectional and longitudinal ultrasound verification of the correct position of the guidewire within the lumen of the artery (arrows). SB, scaphoid bone; TB, trapezium bone.

Video 5. Ultrasound verification of the introducer sheath guidewire in the lumen of the distal radial artery using axial and longitudinal views.