Research Information System
BALKAN MEDICAL JOURNAL, vol.38, no.4, pp.253-254, 2021 (Journal Indexed in SCI)
To the Editor,
We are very pleased to receive such an interesting paper in relation
with our study “Left distal radial artery access site in primary percutaneous coronary intervention: Is it safe?”1
As the authors stated,
distal radial artery cannulation at the anatomical snuffbox has
become a popular alternative approach for coronary angiography
and/or intervention in recent years. Due to the multiple anatomical
and physiological mechanisms thoroughly described in our previous study, the left distal radial artery has been an innovative and
potential approach for our patients since 2017.2
We feel privileged to respond to the authors’ few comments about
this novel site in the clinical setting:
1. They are absolutely right about the impossibility of drawing
firm conclusions of the safety of this access in female patients
due to the possibility of a lower vascular caliber and fragile
tissue characteristics. The relevant reference that the authors
have related these features to was a study done by Naito T et
al., where the caliber of the distal radial artery was found as
2.02 ± 0.44 mm.3
Interestingly, another study implemented
by Norimatsu et al. showed that the caliber of the distal radial
branch was 2.6 ± 0.5 mm, higher than the aforementioned
study, thus implying variability in its caliber.4
Of note, these
studies, done in Japan, have mostly used the right distal
radial artery for caliber measurement––a feature that could
be greatly differentiated from the relevant left side distal
branch. In addition, difference in ethnicity could be another
factor necessitating non-generalizability of the caliber of the
distal radial artery at the anatomical snuffbox. Relating to
this gap in information for the Turkish population, we completed a prospective study, already under review for publication, demonstrating that the caliber of the left distal radial
artery at the anatomical snuffbox is 2.21 ± 0.38 mm, implying compatibility with a six French radial sheath. Higher
rates of complications can be seen in the conventional radial
approach, due to the deeper location of the main radial artery,
being an area not restricted, and where bleeding or hematoma can be easily enlarged. In contrast, as we have stated in
our study, the compact and restricted triangular area of the
left distal radial branch could not pose as many complications as in the conventional radial area, due to its restricted
anatomical structure and so being more protective against
radial occlusion.1
Another important finding is its preservation of endothelial function, in comparison with the conventional radial artery. This is one of the mechanisms of vascular
protection that was found in our recently published study.5
The conclusion of our study was only in relation with the
results of this retrospective representative study, and not in
generalizing the idea. It was further stated that “randomized
controlled trials in comparison with other (conventional
radial and/or femoral) access sites will accurately show its
deserved place in the acute management of ST segment elevation myocardial infarction (STEMI) patients.”
2. We do agree with the implementation of ultrasonography
(USG) as an additional supporting tool to firstly assess the
caliber of the distal radial branch for appropriate selection of
the radial sheath. However, in the acute clinical setting of
STEMI, it was not possible, and we were encouraged by the
fact of the experience of at least 2 years, having performed
500 elective diagnostic and interventional coronary procedures. Indeed, the authors’ estimation is of great importance
and we totally agree again with the idea of incorporating
USG measurement of the distal radial branch, especially in
female patients and those with lower arm circumference.
3. Operator experience is of paramount importance in order to
prevent any vascular complication during distal radial catheterization. As we mentioned above, we had a high experience that could be acceptable for use in primary percutaneous
coronary intervention, the main feature accounting for a successful procedure with no vascular complications. However,
because of the small size and the retrospective design of the
Radial Artery Cannulation at the Anatomical Snuffbox
Soydan and Akın.
Address for Correspondence: Elton Soydan, Department of Cardiology, Ege University School of Medicine, İzmir, Turkey
e-mail: eltonsoydan@hotmail.com
DOI: 10.5152/balkanmedj.2021.21252
Available at www.balkanmedicaljournal.org
ORCID iDs of the authors: E.S. 0000-0002-9897-5484; M.A. 0000-0002-1850-9118.
Cite this article as:
Soydan E, Akın M. In response to: “Radial artery cannulation at the anatomical snuffbox: Hype or hope in interventional cardiology?”. Balkan Med J. 2021 2021;38(4):253-254.
Copyright@Author(s) - Available online at http://balkanmedicaljournal.org/
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Letter to the Editor
In response to: “Radial Artery Cannulation at the Anatomical Snuffbox:
Hype or Hope in Interventional Cardiology?”
Elton Soydan , Mustafa Akın
Department of Cardiology, Ege University School of Medicine, İzmir, Turkey
Soydan and Akın. Radial Artery Cannulation at the Anatomical Snuffbox
Balkan Med J, Vol. 38, No.4, 2021
254
study, we should be cautious about firm conclusions, thus
necessitating prospective multicenter randomized controlled
trials to better show its deserved place in the acute setting of
STEMI. Regarding local anesthesia, different from the conventional radial cannulation, we have previously experienced loss of pulse of the distal radial branch at the anatomical
snuffbox area after administering it before artery puncture.
The possible mechanism of this feature was thought to be
linked to the restricted area surrounded by bony structures,
making the injection act as a mass to the relevant branch and
decrease its pulsation feature. That is why we first punctured
the artery with a 21 gauge open needle and then injected the
local anesthesia, and lastly introduced the radial sheath: an
issue that did not bother the patients.
Multiple studies have shown this novel radial approach to be
protective, in comparison with the conventional one. Thus, as
the authors described, radial artery cannulation at the anatomical
snuffbox is a promising strategy in diagnostic and interventional
coronary procedures. Indeed, these results should encourage us
for the sake of desire for innovation in interventional cardiology.
Increasing experience, combined with transparent perseverance as
well, will certainly make us hopeful, with no doubts toward new
approaches such as distal radial artery access and the possibility of
reaching firm conclusions in the future.
Finally, we want to express our sincere appreciation for this scientific, high-quality letter on the distal radial artery.
Conflict of Interest: The authors have no conflicts of interest to declare.