A NOVEL
APPROACH

Dorsal Access to Radial Artery provides
excellent procedural success and safety

Transradial access has become the default strategy for routine coronary procedure, but there is always scope for improvement. A new technique of accessing the distal radial artery in the anatomical snuffbox is introduced as a safe and feasible approach and is currently gaining interest as an alternative to traditional wrist puncture for radial artery catheterisation.
A 62-year-old hypertensive male, who had undergone coronary Angioplasty a year back was admitted to BLK Super Speciality Hospital with complaints of chest pain of recent onset duration. His ECG was unremarkable, however, troponin I levels were elevated.

Coronary Angiography was performed from the distal right radial artery in the anatomical snuffbox. The radial artery was cannulated with 20 gauge needle, and 5Fr Terumo Radifocus Introducer II sheath was introduced into the artery. Two stents in ostio-proximal and mid to distal LAD were patent. However, the intervening area between the two stents had 70-75% tubular stenosis. IVUS imaging was opted to ascertain the plaque burden and morphology. 5Fr Terumo radial sheath was upgraded to 6Fr Terumo Radifocus Introducer II sheath in anatomical snuffbox. IVUS imaging using Boston Scientific Opticross (3F x 135 cm) revealed significant plaque burden, entailing coronary Angioplasty which was accomplished using stent Xience Prime 3 X 28 mm in LAD.

The anatomical snuffbox is a triangular shaped depression on the radial, dorsal aspect of the hand at the level of the carpal bones. Within this narrow triangular space, various structures are located, including the distal radial artery (RA), a branch of the radial nerve, and

the cephalic vein. The RA gives off the superficial palmar branch before curving around the wrist. The superficial palmar branch usually anastomoses with the end of the ulnar artery (UA) to complete the superficial palmar arch (SPA). Thereafter, the RA passes across the floor of the anatomical snuffbox and through the first interosseous space, crosses the palm, and ends up completing the deep palmar arch (DPA) at the fifth metacarpal base with the deep palmar branch of the UA.

The snuffbox approach has numerous advantages over conventional radial access. First, the approach reduces the risk of occlusion in the RA located proximal to the wrist, a frequent finding in patients who develop a forearm RA occlusion due to puncture trauma or hemostasis trauma at the traditional radial puncture site. Also, even if the vascular sheath has blocked the artery, blood supply to the hand would be maintained via the SPA. Second, hard structures (carpal bones) just underneath the access site and small diameter of distal RA in the snuffbox makes hemostasis easy. Third, subcutaneous hematoma rarely spreads on the upper part of the forearm. Fourth, no need for compression around the wrist as it makes the wrist free to move, which limits venous congestion of the hand. Fifth, in case of vasospasm and hematoma from unsuccessful needling which makes further trials harder, an operator could easily move to the conventional radial approach. Sixth, for patients with chronic kidney disease, vascular injury caused by conventional radial approach occasionally precludes arterio-venous fistula formation for haemodialysis. The snuffbox approach spares the site for future arterio-venous fistula. Seventh, the snuffbox saves more undamaged length of the RA for potential coronary artery bypass surgery candidates.

 

Dr. Neeraj Bhalla

Dr. Neeraj Bhalla
Sr. Consultant
& Director
BLK Heart Centre
BLK Super Speciality
Hospital, New Delhi

Dr. Amit Goel

Dr. Amit Goel
Associate Consultant
BLK Heart Centre
BLK Super Speciality
Hospital, New Delhi

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