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Distal Transradial Access in Anatomical Snuffbox for Coronary Angiography and Intervention: An Updated Meta-Analysis

Distal Transradial Access in Anatomical Snuffbox for Coronary Angiography and Intervention: An... Hindawi Journal of Interventional Cardiology Volume 2021, Article ID 7099044, 11 pages https://doi.org/10.1155/2021/7099044 ResearchArticle Distal Transradial Access in Anatomical Snuffbox for Coronary Angiography and Intervention: An Updated Meta-Analysis 1 2 2 2 2 Chendi Liang , Qinghua Han, Yongping Jia, Chunyu Fan, and Gang Qin Shanxi Medical University, Taiyuan, Shanxi, China Department of Cardiology, e First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China Correspondence should be addressed to Gang Qin; qgsdyy@163.com Received 23 April 2021; Accepted 14 July 2021; Published 22 July 2021 Academic Editor: Michael C. Kim Copyright © 2021 Chendi Liang et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. *e previous meta-analysis has assessed that distal transradial access (dTRA) in anatomical snuffbox is safe and effective for coronary angiography and intervention and can reduce radial artery occlusion. However, since the publication of the previous meta-analysis, several observational studies have been added, so we performed an updated meta-analysis to include more eligible studies to compare distal transradial access in anatomical snuffbox with conventional transradial access (cTRA).Method. Pubmed, Embase, and Cochrane Library databases were searched for relevant studies from the literature published until 5 January 2021 to evaluate catheterization/puncture failure, hematoma, radial artery spasm, radial artery occlusion (RAO), access time, fluoroscopy time, radiation dose area product, total procedure time, and hemostatic device removal time. *e pooled odds ratio (OR), weighted mean difference (WMD), and standardized mean difference (SMD) with 95% confidence interval (95% CI) were calculated for dichotomous and continuous variables, respectively.Results. A total of 9,054 patients from 14 studies were included in the meta-analysis, and we found no significant difference in catheterization/puncture failure (OR �1.94, 95CI [0.97, 3.86], P � 0.06), hematoma (OR �0.97, 95CI [0.55, 1.73], P � 0.926), radial artery spasm (OR �0.76, 95CI [0.43, 1.36], P � 0.354), total procedure time (SMD �0.23, 95CI [−0.21, 0.68], P � 0.308), or radiation dose area product (WMD �216.88Gy/cm , 95CI [−126.24, 560.00], P � 0.215), but dTRA had a lower incidence of RAO (OR �0.39, 95CI [0.23, 0.66], P<0.001), shorter he- mostatic device removal time (WMD � −66.62min, 95CI [−76.68, −56.56], P<0.001), longer access time (SMD �0.32, 95CI [0.08, 0.56], P � 0.008), and longer fluoroscopy time (SMD �0.16, 95CI [−0.00, 0.33], P � 0.05) than cTRA.Conclusion. Compared with the cTRA, the dTRA has a lower incidence of radial artery occlusion and shorter hemostatic device removal time, which is worthy of further evaluation in clinical practice. more prone to complications such as radial artery spasm and 1. Introduction radial artery occlusion (RAO) [2, 3], which can easily Compared with the transfemoral access, the transradial prolong the procedure time, choosing other arterial access, access is now widely used in coronary angiography and and increasing patient discomfort. intervention, with the advantage of reducing the risk of *e distal transradial access (dTRA) in anatomical bleeding, lowering the incidence of postoperative adverse snuffbox is a new method proposed by Kiemeneij in 2017, events, and improving postoperative comfort [1]. However, which is safe and effective in performing coronary angi- due to the low release of nitric oxide, endothelial damage, ography and intervention to reduce hemostasis time [4]. and reduced blood flow caused by the insertion of the sheath Since the method was proposed, a meta-analysis [5] and and catheter, the conventional transradial access (cTRA) is several observational studies comparing the advantages and 2 Journal of Interventional Cardiology 2 2 assessed withI disadvantages of cTRA versus dTRA have emerged. Since . IfI >50%, a random-effect model was used, the publication of the previous meta-analysis, some addi- and sensitivity analysis was performed by removing outlier tional observational studies have been added. *erefore, this studies. *e Egger test was used to evaluate publication bias. meta-analysis aimed to compare cTRA versus dTRA. A two-sided P<0.05 was considered statistically different. If publication bias was present, effect sizes were recalculated using the trim and fill method. 2. Materials and Methods *is work was conducted and reported according to Meta- 3. Results analysis Of Observational Studies in Epidemiology (MOOSE) [6]. In addition, this meta-analysis has been 3.1. e Basic Characteristics of the Included Studies. *e registered with PROSPERO (registration number: initial search identified 987 articles and 257 duplicate arti- CRD42020208776). cles, 624 irrelevant articles were excluded based on the title and abstract, and 92 articles were excluded after viewing the full text. Finally, 14 studies met the inclusion criteria. Fig- 2.1.SearchStrategyandInclusionCriteria. We used Pubmed, ure 1 shows the detailed search process. Embase, and Cochrane Library databases to find studies of Table 1 presents basic information of the 14 eligible dTRA in anatomical snuffbox versus cTRA for coronary studies, including 2 randomized controlled trials and 12 angiography and intervention, using the following search cohort studies (including 1 retrospective study and 11 terms: “distal,” “snuffbox,” “snuff box,” “transradial,” “ra- prospective studies), involving a total of 9,054 patients with dial,” “coronary angiography,” and “Percutaneous Coronary sample sizes ranging from 41 to 5,874. *e included studies Intervention.” *e retrieval time was performed from the were all of high quality. literature published until 5 January 2021, with no language restrictions. References in relevant articles were also accessed to find eligible studies. See online supplementary 3.2. Meta-Analysis of Indicators file 1 for detailed search strategies. 3.2.1.Catheterization/PunctureFailure. 11 studies described *e studies included in this meta-analysis were required catheterization/puncture failure. *e meta-analysis showed to meet the following criteria: (1) adults undergoing coro- similar catheterization/puncture failure between dTRA and nary angiography or intervention; (2) randomized con- cTRA, with no statistical significance (OR �1.94, 95CI [0.97, trolled trials or observational studies of dTRA in anatomical 3.86], P � 0.06; I �78.5%, P<0.001). We conducted a snuffbox versus cTRA; (3) studies that included one of the sensitivity analysis by removing outlier studies, heteroge- following indicators: catheterization/puncture failure, he- neity was significantly reduced after excluding the studies by matoma, radial artery spasm, radial artery occlusion, access Bhambhani [11] and Koutouzis [17], and there was still no time, fluoroscopy time, radiation dose area product, total statistical difference (OR �1.06, 95CI [0.69, 1.64], P � 0.788; procedure time, and hemostatic device removal time; (5) I �38.2%, P � 0.114). *e Egger test suggested the existence case reports, conference abstracts, letters, reviews, and of publication bias among the studies (P � 0.015), so we comments were excluded; and (6) the language of the studies used the trim and fill method to recalculate the effect size: the was restricted to English. number of studies did not change, and there was still no statistical difference between them (OR �1.927, 95CI [0.981, 2.2. Data Extraction and Quality Assessment. Two authors 3.785]), suggesting that the result was robust (see Figure 2). independently read the full text and extracted basic infor- mation about the eligible studies: first author, study type, 3.2.2. Hematoma. Eight studies described hematoma. *e country, publication year, sample size, basis characteristics of included patients, and indicators. For cohort studies, we meta-analysis showed the incidence of hematoma was similar between dTRA and cTRA, with no statistical sig- used the nine-star Newcastle–Ottawa scale [7] to assess quality in terms of study population selection, compara- nificance (OR �0.97, 95CI [0.55, 1.73], P � 0.926; I �0.0%, P � 0.733). *e Egger test suggested the existence of pub- bility, and outcome. For randomized controlled trials, we used the Jadad scale [8] to evaluate quality in terms of the lication bias among the studies (P � 0.004), so we used the trim and fill method to recalculate the effect size: the number randomization method, blinding, loss of follow-up, and withdrawal, with a score ≤2 indicating low quality and a of studies did not change, and there was still no statistical difference (OR �0.973, 95CI [0.548, 1.728]), suggesting that score ≥3 indicating high quality. Any differences were re- the result was robust (see Figure 3). solved by the third author. 2.3.StatisticalAnalysis. We used Stata version 14.0 for meta- 3.2.3. Radial Artery Spasm. Six studies described radial analysis. *e pooled odds ratio (OR) and its 95% confidence artery spasm. *e meta-analysis showed the incidence of interval (95% CI) were calculated for dichotomous variables. radial artery spasm was similar between dTRA and cTRA, *e weighted mean difference (WMD) or the standardized with no statistical significance (OR �0.76, 95CI [0.43, 1.36], mean difference (SMD) and its 95% CI were calculated for P � 0.354;I �0.0%, P � 0.893) (see Figure 4). *e Egger test continuous variables. Heterogeneity among the studies was showed no publication bias among the studies (P � 0.437). Journal of Interventional Cardiology 3 Records identified through Additional records identified database searching through other sources (n = 984) (n = 3) Records aer duplicates removed (n = 730) Records screened Records excluded (n = 730) (n = 624) Full-text articles excluded, with reasons (n = 92): Case reports (n = 8) Non-English articles (n = 4) Full-text articles assessed Conference abstracts (n = 45) for eligibility (n = 106) Comments (n = 4) No sufficient data (n = 28) Letters (n = 2) Review (n = 1) Studies included in quantitative synthesis (meta-analysis) (n = 14) Figure 1: Flow chart of the search process. 3.2.4. Radial Artery Occlusion (RAO). Seven studies de- 3.2.7. Radiation Dose Area Product (DAP). *ree studies scribed RAO. *e meta-analysis showed compared with described DAP. *e meta-analysis showed the DAP was cTRA, the incidence of RAO was lower in dTRA, with the similar between dTRA and cTRA, with no statistical sig- statistical difference between studies (OR �0.39, 95CI [0.23, nificance (WMD �216.88Gy/cm , 95CI [−126.24, 560.00], 2 2 0.66], P<0.001; I �0.0%, P � 0.989) (see Figure 5). *e P � 0.215;I �0.0%, P � 0.567) (see Figure 8). *e Egger test Egger test showed no publication bias among the studies showed no publication bias among the studies (P � 0.414). (P � 0.115). 3.2.8. Total Procedure Time. Five studies described total 3.2.5. Access Time. Six studies described access time. *e procedure time. *e meta-analysis showed the total pro- meta-analysis showed compared with cTRA, the access time cedure time was similar between dTRA and cTRA, with no was longer in dTRA, with the statistical difference between statistical significance (SMD �0.23, 95CI [−0.21, 0.68], 2 2 studies (SMD �0.32, 95CI [0.08, 0.56], P � 0.008;I �86.7%, P � 0.308; I �91.8%, P<0.001) (see Figure 9). We con- P<0.001) (see Figure 6). We conducted a sensitivity analysis ducted a sensitivity analysis by removing the outlier study, by removing the outlier study, heterogeneity was signifi- heterogeneity was significantly reduced after excluding the cantly reduced after excluding the study by Wang [22], and study by Bhambhani [11], and there was still no statistical there was still a statistical difference (SMD �0.41, 95CI [0.29, difference (SMD � −0.03, 95CI [−0.17, 0.11], P � 0.642; 2 2 0.54], P<0.001; I �32.5%, P � 0.205). *e Egger test I �13%, P � 0.328). *e Egger test showed no publication showed no publication bias among the studies (P � 0.463). bias among the studies (P � 0.398). 3.2.6.FluoroscopyTime. Four studies described fluoroscopy 3.2.9. Hemostatic Device Removal Time. *ree studies de- time. *e meta-analysis showed compared with cTRA, the scribed hemostatic device removal time. *e meta-analysis fluoroscopy time was longer in dTRA, with the statistical showed compared with cTRA, the hemostatic device re- difference between studies (SMD �0.16, 95CI [−0.00, 0.33], moval time was shorter in dTRA, with the statistical dif- P � 0.05;I �0.0%, P � 0.920) (see Figure 7). *e Egger test ference between studies (WMD � −66.62min, 95CI [−76.68, showed no publication bias among the studies (P � 0.246). −56.56], P<0.001; I �55.7%, P � 0.105) (see Figure 10). Eligibility Identification Included Screening 4 Journal of Interventional Cardiology Table 1: Basic information of the included studies. Diabetes Male Overall Hypertension Smoking Hyperlipidemia Jadad Author Year Country Study type Sample mellitus BMI Indicators NOS score (%) age (%) (%) (%) score (%) 408 (202 64.9 69.2 37.6 33.3 26.5 Aoi [9] 2019 USA Retrospective 85.6 vs.95.1 83.7 vs.91.7 1, 2, 3, 5, 9 7 (3/2/2) — vs. 206) vs.62.6 vs.68.8 vs.45.6 vs.25.2 vs.27.1 100 (50 Amin [10] 2017 Bangladesh Prospective — — — — — — — 1, 2, 4 7 (4/0/3) — vs.50) Bhambhani 200 (100 84 54.6 2020 India Prospective 59 vs.50 40 vs.35 39 vs.32 — — 1, 5, 6, 7, 8 9 (4/2/3) — [11] vs.100) vs.73 vs.54.9 Coughlan 94 (47 83 61 2018 Ireland Prospective — — — — — 6, 7, 8, 9 9 (4/2/3) — [12] vs.47) vs.74.5 vs.61.8 164 (82 58.5 57.7 25.6 43.9 Gajurel [13] 2018 Nepal Prospective 35.3 vs.29.2 20.7 vs.12.1 — 1, 2, 3 9 (4/2/3) — vs.82) vs.53.6 vs.57.2 vs.18.2 vs.32.9 Hammami 177 (82 62 59.23 2021 Tunisia Prospective 40 vs.44 45 vs.40 41.5 vs.42 — — 1, 3, 4 9 (4/2/3) — [14] vs. 95) vs.70 vs.60.38 41 (17 70.6 47.1 35.3 Kis [15] 2020 Turkey Prospective — 70.6 vs.79.2 41.2 vs.37.5 — 2, 3 9 (4/2/3) — vs.24) vs.70.8 vs.33.3 vs.29.2 Kaledin [16] 2017 Russia Prospective (2775 — — — — — — — 1 7 (4/0/3) — vs.3099) Koutouzis 200 (100 74 63.8 28.6 1, 2, 3, 4, 5, 3 (2/0/ 2019 Greece Randomized 73 vs.63 27 vs.28 35 vs.28 71 vs.59 — [17] vs.100) vs.77 vs.62.8 vs.29 6, 7, 8 1) 900 (450 45.56 55.28 10.67 27.56 24.06 3 (2/0/ Lin [18] 2020 China Randomized 24.89 vs.25.11 — 1, 2, 4, 5, 9 — vs.450) vs.50 vs.58.81 vs.12.44 vs.22.44 vs.24.36 1) 80 (40 57.5 54.3 Lu [19] 2020 China Prospective — 15 vs.17.5 — — — 1, 2, 4 8 (4/2/2) — vs.40) vs.62.5 vs.56.4 Roghani- 74.2 67.1 28.4 126 (70 62.8 55.1 Dehkordi 2020 Iran Prospective 57.1 vs.67.8 31.4 vs.28.6 1, 5, 6, 8 9 (4/2/3) — vs.56) vs.64.3 vs.56.5 vs.80.3 vs.78.6 vs.27.2 [20] 70 (27 63 40.7 33.3 Soydan [21] 2021 Turkey Prospective — 77.8 vs.76.7 48.1 vs.30.2 — 4 9 (4/2/3) — vs.43) vs.72.1 vs.39.5 vs.27.9 620 (312 51.3 50.1 31.4 56.4 1, 2, 3, 4, 5, Wang [22] 2020 China Prospective 60.6 vs.56.5 44.2 vs.41.9 — 8 (4/2/2) — vs.308) vs.51 vs.51.2 vs.28.2 vs.54.5 8 1- Catheterization/puncture failure; 2- hematoma; 3- radial artery spasm; 4- radial artery occlusion; 5- access time; 6- fluoroscopy time; 7- radiation dose area product; 8- total procedure time; 9- hemostatic device removal time. Journal of Interventional Cardiology 5 Study ID OR (95% CI) Weight (%) Aoi 0.81 (0.21, 3.07) 9.27 Bhambhani 9.12 (2.63, 31.59) 9.69 Hammami 2.38 (0.43, 13.37) 7.50 Koutouzis 21.00 (4.86, 90.77) 8.63 Lin 1.21 (0.60, 2.43) 12.36 Lu 15.26 (0.83, 280.72) 4.01 Roghani−Dehkordi 2.28 (0.58, 9.03) 9.04 Wang 1.23 (0.58, 2.60) 12.12 Amin 1.00 (0.14, 7.39) 6.45 Gajurel 0.66 (0.11, 4.05) 7.13 Kaledin 0.63 (0.47, 0.85) 13.79 Overall (I = 78.5%, p = 0.000) 1.94 (0.97, 3.86) 100.00 Note: weights are from random effects analysis 0.00356 1 281 (a) −2 0 2 4 6 8 Precision Study Regression line 95% CI for intercept (b) Filled funnel plot with pseudo 95% confidence limits −2 0 0.5 1 1.5 s.e. of: theta, filled (c) Figure 2: (a) Forest plot of catheterization/puncture failure for dTRA compared to cTRA. (b) Egger test was used to quantitatively assess publication bias in catheterization/puncture failure (P � 0.015). (c) Trim and fill funnel plot showed that no new studies were added. SND of effect estimate eta, filled 6 Journal of Interventional Cardiology Study ID OR (95% CI) Weight (%) Aoi 1.44 (0.45, 4.62) 24.33 Kis 0.26 (0.01, 5.71) 3.43 Koutouzis 1.00 (0.06, 16.21) 4.25 Lin 1.38 (0.55, 3.47) 38.95 Lu 0.33 (0.01, 8.22) 3.16 Wang 0.79 (0.21, 2.96) 18.81 Amin 0.19 (0.01, 4.10) 3.52 Gajurel 0.20 (0.01, 4.13) 3.54 Overall (I = 0.0%, p = 0.733) 0.97 (0.55, 1.73) 100.00 0.00899 1 111 (a) −2 0 0.5 1 1.5 2 Precision Study Regression line 95% CI for intercept (b) Filled funnel plot with pseudo 95% confidence limits −2 −4 0 0.5 1 1.5 2 s.e. of: theta, filled (c) Figure 3: (a) Forest plot of hematoma for dTRA compared to cTRA. (b) Egger test was used to quantitatively assess publication bias in hematoma (P � 0.004). (c) Trim and fill funnel plot showed that no new studies were added. SND of effect estimate Theta, filled Journal of Interventional Cardiology 7 Study ID OR (95% CI) Weight (%) Aoi 5.15 (0.25, 107.93) 3.63 Hammami 0.71 (0.22, 2.25) 25.03 Kis 0.45 (0.02, 11.66) 3.16 Koutouzis 0.74 (0.16, 3.41) 14.48 Wang 0.73 (0.30, 1.76) 43.50 Gajurel 0.66 (0.11, 4.05) 10.19 Overall (I = 0.0%, p = 0.893) 0.76 (0.43, 1.36) 100.00 0.00927 1 108 Figure 4: Forest plot of radial artery spasm for dTRA compared to cTRA. Study ID OR (95% CI) Weight (%) Hammami 0.16 (0.01, 3.15) 3.16 Koutouzis 0.53 (0.17, 1.65) 21.92 Lin 0.40 (0.17, 0.98) 35.36 Lu 0.33 (0.01, 8.22) 2.68 Soydan 0.30 (0.01, 6.53) 2.96 Wang 0.36 (0.14, 0.93) 30.92 Amin 0.19 (0.01, 4.10) 2.99 Overall (I = 0.0%, p = 0.989) 0.39 (0.23, 0.66) 100.00 0.00815 1 123 Figure 5: Forest plot of radial artery occlusion for dTRA compared to cTRA. We conducted a sensitivity analysis by removing the outlier spasm, total procedure time, or radiation dose area product, study, heterogeneity was significantly reduced after ex- but dTRA had a lower incidence of RAO, shorter hemostatic cluding the study by Lin [18], and there was still a statistical device removal time, and longer access time and fluoroscopy difference (WMD � −72.83min, 95CI [−82.39, −63.27], time than cTRA. P<0.001; I �0.0%, P � 0.656). *e Egger test showed no *e anatomical snuffbox is a triangular depression of the publication bias among the studies (P � 0.588). tip towards the thumb when the thumb is fully extended. *e radial artery in the anatomical snuffbox is superficially lo- cated and can be palpated [23]. *e vascular diameter of the 4. Discussion distal radial artery in the anatomical snuffbox is usually smaller than that of the radial artery at the wrist, with a ratio *is work aimed to evaluate the differences between dTRA of about 0.8–0.9 [24], while the diameter of the distal radial in anatomical snuffbox versus cTRA. Our meta-analysis of artery in men is larger than that in women [25], which means the 14 included studies found no significant differences in that successful distal radial artery catheterization/puncture catheterization/puncture failure, hematoma, radial artery 8 Journal of Interventional Cardiology Study ID SMD (95% CI) Weight (%) Aoi 0.43 (0.23, 0.62) 17.80 Bhambhani 0.57 (0.26, 0.88) 15.13 Koutouzis 0.61 (0.33, 0.90) 15.74 Lin 0.33 (0.19, 0.46) 19.06 Roghani−Dehkordi 0.18 (−0.19, 0.55) 13.68 Wang −0.13 (−0.29, 0.02) 18.59 Overall (I = 86.7%, p = 0.000) 0.32 (0.08, 0.56) 100.00 Note: weights are from random effects analysis −0.895 0 0.895 Figure 6: Forest plot of access time for dTRA compared to cTRA. Study ID SMD (95% CI) Weight (%) Bhambhani 0.13 (−0.17, 0.43) 29.26 Coughlan 0.18 (−0.22, 0.59) 16.29 Koutouzis 0.12 (−0.16, 0.40) 34.74 Roghani−Dehkordi 0.27 (−0.10, 0.64) 19.71 Overall (I = 0.0%, p = 0.920) 0.16 (−0.00, 0.33) 100.00 −0.642 0 0.642 Figure 7: Forest plot of fluoroscopy time for dTRA compared to cTRA. Study ID WMD (95% CI) Weight (%) Bhambhani 1349.70 (−762.97, 3462.37) 2.64 Coughlan 206.66 (−912.53, 1325.85) 9.40 Koutouzis 184.00 (−181.84, 549.84) 87.96 Overall (I = 0.0%, p = 0.567) 216.88 (−126.24, 560.00) 100.00 −3462 0 3462 Figure 8: Forest plot of radiation dose area product for dTRA compared to cTRA. Journal of Interventional Cardiology 9 Study ID SMD (95% CI) Weight (%) Bhambhani 1.15 (0.83, 1.48) 19.85 Coughlan −0.11 (−0.52, 0.29) 18.78 Koutouzis 0.13 (−0.14, 0.41) 20.45 Roghani−Dehkordi 0.12 (−0.25, 0.49) 19.31 Wang −0.12 (−0.28, 0.03) 21.61 Overall (I = 91.8%, p = 0.000) 0.23 (−0.21, 0.68) 100.00 Note: weights are from random effects analysis −1.48 0 1.48 Figure 9: Forest plot of total procedure time for dTRA compared to cTRA. Study ID WMD (95% CI) Weight (%) Aoi −74.00 (−84.85, −63.15) 35.82 Coughlan −68.80 (−88.98, −48.62) 17.69 Lin −60.10 (−67.38, −52.82) 46.49 Overall (I = 55.7%, p = 0.105) −66.62 (−76.68, −56.56) 100.00 Note: weights are from random effects analysis −89 0 89 Figure 10: Forest plot of hemostatic device removal time for dTRA compared to cTRA. seems to be more challenging. *e overall catheterization/ the terminal of the radial artery forms the deep palmar arch puncture failure of dTRA included in this meta-analysis was at the distal end of the anatomical snuffbox with the deep higher than that of cTRA, but there was no statistically palmar branch of the ulnar artery. *ere are abundant significant difference (4.3% VS 3.8%, P>0.05), and the collateral anastomoses between the two arches. Even if the access time was prolonged in dTRA, but did not affect total distal radial artery is occluded, antegrade flow is maintained procedure time. Bhambhani [11] performed distal radial and the risk of retrograde thrombosis is reduced [23, 28, 29]. artery cannulation in 100 patients and found access time in *is meta-analysis found that compared with cTRA, he- dTRA was progressively reduced, from 5.89 minutes in the mostatic device removal time was shorter in dTRA (WMD � −66.62min, 95CI [−76.68, −56.56], P<0.001), the first 25 cases to 2.47 minutes in the last 25 cases. Also, Lee [26] found that puncture time stabilized after approximately incidence of radial artery occlusion was lower in dTRA 150 distal radial artery punctures had been performed. (4.6% vs 1.7%, P<0.001), and the incidence of hematoma *erefore, the learning curve must be overcome to master (2.1% vs 1.8%, P � 0.926) and radial artery spasm (3.4% vs the dTRA. 2.6%, P � 0.354) was similar in dTRA, suggesting that the *e anatomical snuffbox is surrounded by soft tissue and dTRA was more comfortable and safer for patients. has a bony base consisting of the scaphoid bone and tra- When performing the left dTRA, the patient can nat- pezium bone, which can be easily compressed to hemostasis, urally place the left hand at the level of the right groin, and the complications of bleeding and hematomas are allowing the operator on the right side of the patient to not uncommon [23, 27]. *e radial artery divides into the su- bend over. *is allows the operator to keep away from the perficial palmar branch near the level of the AS to form the source of radiation and avoid high radiation doses and solve the problem of postoperative restriction of the right hand, superficial palmar arch with the terminal ulnar artery, and 10 Journal of Interventional Cardiology which is extremely comfortable for right-handed patients Acknowledgments [4]. *is meta-analysis found no significant difference in *is work was supported by special projects for the Guid- radiation dose area product between dTRA and cTRA ance of the Transformation of Scientific and Technological (P � 0.215), but the fluoroscopy time in dTRA was pro- Achievements in Shanxi Province (Project no. longed (P � 0.05). As P � 0.05 represents the critical P 201804D131045) and the Transformation and Cultivation value, which is at the borderline of statistical significance, Projects of Scientific and Technological Achievements in this result should be interpreted with more caution and Colleges and Universities of Shanxi Province (Project no. needs to be further demonstrated in large-sample studies. 2020CG028). Despite the advantages of shorter hemostatic device removal time and lower incidence of RAO, the limitations of this novel access should be noted: smaller vascular diameter Supplementary Materials limits the use of large bore sheaths, and longer access time may delay coronary revascularization, especially in cases of Online supplementary file 1: search strategies. (Supple- myocardial infarction. mentary Materials) *ere are some limitations in this meta-analysis. First, publication bias was present in the catheterization/puncture References failure and hematoma. 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Karatasakis, A. Tsoumeleas, E. Lazaris, groups. *erefore, a large sample size of randomized con- A. Ziakas, and M. Koutouzis, “Radial artery occlusion after trolled trials is still needed for further assessment. Finally, transradial coronary catheterization,” Cardiovascular Diag- due to the lack of sufficient data, we did not analyze the nosis and erapy, vol. 7, no. 3, pp. 305–316, 2017. differences in access time and/or radiation exposure between [4] F. Kiemeneij, “Left distal transradial access in the anatomical the left and the right arm, which still need further evaluation. snuffbox for coronary angiography (ldTRA) and interven- tions (ldTRI),” EuroIntervention, vol. 13, no. 7, pp. 851–857, 5. Conclusions [5] M. Hamandi, M. Saad, R. Hasan et al., “Distal versus con- ventional transradial artery access for coronary angiography Compared with the cTRA, the dTRA has a longer access time and intervention: a meta-analysis,” Cardiovascular Revascu- and fluoroscopy time, but this does not affect total procedure larization Medicine, vol. 21, no. 10, pp. 1209–1213, 2020. time or radiation dose area product. Also, the dTRA has a [6] D. F. Stroup, J. A. Berlin, S. C. Morton et al., “Meta-analysis of lower incidence of radial artery occlusion and shorter he- observational studies in epidemiologyA proposal for mostatic device removal time, which is worthy of further reporting,” JAMA, vol. 283, no. 15, pp. 2008–2012, 2000. evaluation in clinical practice. [7] A. Stang, “Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses,” European Journal of Epidemiology, vol. 25, Data Availability no. 9, pp. 603–605, 2010. [8] A. R. Jadad, R. A. Moore, D. Carroll et al., “Assessing the *e datasets used and/or analysed during the current study quality of reports of randomized clinical trials: is blinding are available from the corresponding author on reasonable necessary?” Controlled Clinical Trials, vol. 17, no. 1, pp. 1–12, request. [9] S. Aoi, W. W. Htun, S. Freeo et al., “Distal transradial artery access in the anatomical snuffbox for coronary angiography as Conflicts of Interest an alternative access site for faster hemostasis,” Catheteri- zation and Cardiovascular Interventions, vol. 94, no. 5, *e authors declare no conflicts of interest. pp. 651–657, 2019. [10] M. R. Amin, C. K. Singha, S. K. Banerjee et al., “Comparison of distal transradial in the anatomical snuffbox versus conven- Authors’ Contributions tional transradial access for coronary angiography and in- tervention-an experience in 100 cases,” eJournalofTehran YPJ, CYF, and GQ contributed to the design of this study. University Heart Center, vol. 13, no. 2, pp. 40–45, 2017. CDL and GQ contributed to the literature search and data [11] A. Bhambhani, S. Pandey, A. N. Nadamani, and K. Tyagi, “An extraction. CDL contributed to the writing of the manuscript observational comparison of distal radial and traditional and analysis of the data. Any discrepancies were resolved by radial approaches for coronary angiography,” Journal of the QHH. QHH and GQ contributed to the final version of the Saudi Heart Association, vol. 32, no. 1, pp. 17–24, 2020. manuscript. Journal of Interventional Cardiology 11 [12] J. J. Coughlan, A. Zebrauskaite, S. Arnous, and T. J. Kiernan, clinical experience and future directions,” Cardiology Re- “Left distal trans-radial access facilitates earlier discharge search and Practice, vol. 2019, Article ID 8671306, 7 pages, post-coronary angiography,” Journal of Interventional Car- 2019. [28] C. Liontou, E. Kontopodis, N. Oikonomidis et al., “Distal diology, vol. 31, no. 6, pp. 964–968, 2018. [13] R. M. Gajurel, R. Sahi, H. Shrestha, S. *apa, and R. Khanal, radial access: a review article,” Cardiovascular Revasculari- “Initial experience on anatomical snuff box approach for zation Medicine, vol. 21, no. 3, pp. 412–416, 2020. coronary angiogram & percutaneous coronary intervention in [29] G. A. Sgueglia, A. Di Giorgio, A. Gaspardone, and a tertiary care center Nepal,”WorldJournalofCardiovascular A. Babunashvili, “Anatomic basis and physiological rationale Diseases, vol. 08, no. 12, pp. 578–587, 2018. of distal radial artery access for percutaneous coronary and [14] R. Hammami, F. Zouari, M. A. Ben Abdessalem et al., “Distal endovascular procedures,” JACC: Cardiovascular Interven- radial approach versus conventional radial approach: a tions, vol. 11, no. 20, pp. 2113–2119, 2018. comparative study of feasibility and safety,”LibyanJournalof Medicine, vol. 16, no. 1, Article ID 1830600, 2021. [15] M. 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Hu, “Left distal transradial approach for coronary intervention: insights from early http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Interventional Cardiology Hindawi Publishing Corporation

Distal Transradial Access in Anatomical Snuffbox for Coronary Angiography and Intervention: An Updated Meta-Analysis

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Copyright © 2021 Chendi Liang et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Journal of Interventional Cardiology Volume 2021, Article ID 7099044, 11 pages https://doi.org/10.1155/2021/7099044 ResearchArticle Distal Transradial Access in Anatomical Snuffbox for Coronary Angiography and Intervention: An Updated Meta-Analysis 1 2 2 2 2 Chendi Liang , Qinghua Han, Yongping Jia, Chunyu Fan, and Gang Qin Shanxi Medical University, Taiyuan, Shanxi, China Department of Cardiology, e First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China Correspondence should be addressed to Gang Qin; qgsdyy@163.com Received 23 April 2021; Accepted 14 July 2021; Published 22 July 2021 Academic Editor: Michael C. Kim Copyright © 2021 Chendi Liang et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. *e previous meta-analysis has assessed that distal transradial access (dTRA) in anatomical snuffbox is safe and effective for coronary angiography and intervention and can reduce radial artery occlusion. However, since the publication of the previous meta-analysis, several observational studies have been added, so we performed an updated meta-analysis to include more eligible studies to compare distal transradial access in anatomical snuffbox with conventional transradial access (cTRA).Method. Pubmed, Embase, and Cochrane Library databases were searched for relevant studies from the literature published until 5 January 2021 to evaluate catheterization/puncture failure, hematoma, radial artery spasm, radial artery occlusion (RAO), access time, fluoroscopy time, radiation dose area product, total procedure time, and hemostatic device removal time. *e pooled odds ratio (OR), weighted mean difference (WMD), and standardized mean difference (SMD) with 95% confidence interval (95% CI) were calculated for dichotomous and continuous variables, respectively.Results. A total of 9,054 patients from 14 studies were included in the meta-analysis, and we found no significant difference in catheterization/puncture failure (OR �1.94, 95CI [0.97, 3.86], P � 0.06), hematoma (OR �0.97, 95CI [0.55, 1.73], P � 0.926), radial artery spasm (OR �0.76, 95CI [0.43, 1.36], P � 0.354), total procedure time (SMD �0.23, 95CI [−0.21, 0.68], P � 0.308), or radiation dose area product (WMD �216.88Gy/cm , 95CI [−126.24, 560.00], P � 0.215), but dTRA had a lower incidence of RAO (OR �0.39, 95CI [0.23, 0.66], P<0.001), shorter he- mostatic device removal time (WMD � −66.62min, 95CI [−76.68, −56.56], P<0.001), longer access time (SMD �0.32, 95CI [0.08, 0.56], P � 0.008), and longer fluoroscopy time (SMD �0.16, 95CI [−0.00, 0.33], P � 0.05) than cTRA.Conclusion. Compared with the cTRA, the dTRA has a lower incidence of radial artery occlusion and shorter hemostatic device removal time, which is worthy of further evaluation in clinical practice. more prone to complications such as radial artery spasm and 1. Introduction radial artery occlusion (RAO) [2, 3], which can easily Compared with the transfemoral access, the transradial prolong the procedure time, choosing other arterial access, access is now widely used in coronary angiography and and increasing patient discomfort. intervention, with the advantage of reducing the risk of *e distal transradial access (dTRA) in anatomical bleeding, lowering the incidence of postoperative adverse snuffbox is a new method proposed by Kiemeneij in 2017, events, and improving postoperative comfort [1]. However, which is safe and effective in performing coronary angi- due to the low release of nitric oxide, endothelial damage, ography and intervention to reduce hemostasis time [4]. and reduced blood flow caused by the insertion of the sheath Since the method was proposed, a meta-analysis [5] and and catheter, the conventional transradial access (cTRA) is several observational studies comparing the advantages and 2 Journal of Interventional Cardiology 2 2 assessed withI disadvantages of cTRA versus dTRA have emerged. Since . IfI >50%, a random-effect model was used, the publication of the previous meta-analysis, some addi- and sensitivity analysis was performed by removing outlier tional observational studies have been added. *erefore, this studies. *e Egger test was used to evaluate publication bias. meta-analysis aimed to compare cTRA versus dTRA. A two-sided P<0.05 was considered statistically different. If publication bias was present, effect sizes were recalculated using the trim and fill method. 2. Materials and Methods *is work was conducted and reported according to Meta- 3. Results analysis Of Observational Studies in Epidemiology (MOOSE) [6]. In addition, this meta-analysis has been 3.1. e Basic Characteristics of the Included Studies. *e registered with PROSPERO (registration number: initial search identified 987 articles and 257 duplicate arti- CRD42020208776). cles, 624 irrelevant articles were excluded based on the title and abstract, and 92 articles were excluded after viewing the full text. Finally, 14 studies met the inclusion criteria. Fig- 2.1.SearchStrategyandInclusionCriteria. We used Pubmed, ure 1 shows the detailed search process. Embase, and Cochrane Library databases to find studies of Table 1 presents basic information of the 14 eligible dTRA in anatomical snuffbox versus cTRA for coronary studies, including 2 randomized controlled trials and 12 angiography and intervention, using the following search cohort studies (including 1 retrospective study and 11 terms: “distal,” “snuffbox,” “snuff box,” “transradial,” “ra- prospective studies), involving a total of 9,054 patients with dial,” “coronary angiography,” and “Percutaneous Coronary sample sizes ranging from 41 to 5,874. *e included studies Intervention.” *e retrieval time was performed from the were all of high quality. literature published until 5 January 2021, with no language restrictions. References in relevant articles were also accessed to find eligible studies. See online supplementary 3.2. Meta-Analysis of Indicators file 1 for detailed search strategies. 3.2.1.Catheterization/PunctureFailure. 11 studies described *e studies included in this meta-analysis were required catheterization/puncture failure. *e meta-analysis showed to meet the following criteria: (1) adults undergoing coro- similar catheterization/puncture failure between dTRA and nary angiography or intervention; (2) randomized con- cTRA, with no statistical significance (OR �1.94, 95CI [0.97, trolled trials or observational studies of dTRA in anatomical 3.86], P � 0.06; I �78.5%, P<0.001). We conducted a snuffbox versus cTRA; (3) studies that included one of the sensitivity analysis by removing outlier studies, heteroge- following indicators: catheterization/puncture failure, he- neity was significantly reduced after excluding the studies by matoma, radial artery spasm, radial artery occlusion, access Bhambhani [11] and Koutouzis [17], and there was still no time, fluoroscopy time, radiation dose area product, total statistical difference (OR �1.06, 95CI [0.69, 1.64], P � 0.788; procedure time, and hemostatic device removal time; (5) I �38.2%, P � 0.114). *e Egger test suggested the existence case reports, conference abstracts, letters, reviews, and of publication bias among the studies (P � 0.015), so we comments were excluded; and (6) the language of the studies used the trim and fill method to recalculate the effect size: the was restricted to English. number of studies did not change, and there was still no statistical difference between them (OR �1.927, 95CI [0.981, 2.2. Data Extraction and Quality Assessment. Two authors 3.785]), suggesting that the result was robust (see Figure 2). independently read the full text and extracted basic infor- mation about the eligible studies: first author, study type, 3.2.2. Hematoma. Eight studies described hematoma. *e country, publication year, sample size, basis characteristics of included patients, and indicators. For cohort studies, we meta-analysis showed the incidence of hematoma was similar between dTRA and cTRA, with no statistical sig- used the nine-star Newcastle–Ottawa scale [7] to assess quality in terms of study population selection, compara- nificance (OR �0.97, 95CI [0.55, 1.73], P � 0.926; I �0.0%, P � 0.733). *e Egger test suggested the existence of pub- bility, and outcome. For randomized controlled trials, we used the Jadad scale [8] to evaluate quality in terms of the lication bias among the studies (P � 0.004), so we used the trim and fill method to recalculate the effect size: the number randomization method, blinding, loss of follow-up, and withdrawal, with a score ≤2 indicating low quality and a of studies did not change, and there was still no statistical difference (OR �0.973, 95CI [0.548, 1.728]), suggesting that score ≥3 indicating high quality. Any differences were re- the result was robust (see Figure 3). solved by the third author. 2.3.StatisticalAnalysis. We used Stata version 14.0 for meta- 3.2.3. Radial Artery Spasm. Six studies described radial analysis. *e pooled odds ratio (OR) and its 95% confidence artery spasm. *e meta-analysis showed the incidence of interval (95% CI) were calculated for dichotomous variables. radial artery spasm was similar between dTRA and cTRA, *e weighted mean difference (WMD) or the standardized with no statistical significance (OR �0.76, 95CI [0.43, 1.36], mean difference (SMD) and its 95% CI were calculated for P � 0.354;I �0.0%, P � 0.893) (see Figure 4). *e Egger test continuous variables. Heterogeneity among the studies was showed no publication bias among the studies (P � 0.437). Journal of Interventional Cardiology 3 Records identified through Additional records identified database searching through other sources (n = 984) (n = 3) Records aer duplicates removed (n = 730) Records screened Records excluded (n = 730) (n = 624) Full-text articles excluded, with reasons (n = 92): Case reports (n = 8) Non-English articles (n = 4) Full-text articles assessed Conference abstracts (n = 45) for eligibility (n = 106) Comments (n = 4) No sufficient data (n = 28) Letters (n = 2) Review (n = 1) Studies included in quantitative synthesis (meta-analysis) (n = 14) Figure 1: Flow chart of the search process. 3.2.4. Radial Artery Occlusion (RAO). Seven studies de- 3.2.7. Radiation Dose Area Product (DAP). *ree studies scribed RAO. *e meta-analysis showed compared with described DAP. *e meta-analysis showed the DAP was cTRA, the incidence of RAO was lower in dTRA, with the similar between dTRA and cTRA, with no statistical sig- statistical difference between studies (OR �0.39, 95CI [0.23, nificance (WMD �216.88Gy/cm , 95CI [−126.24, 560.00], 2 2 0.66], P<0.001; I �0.0%, P � 0.989) (see Figure 5). *e P � 0.215;I �0.0%, P � 0.567) (see Figure 8). *e Egger test Egger test showed no publication bias among the studies showed no publication bias among the studies (P � 0.414). (P � 0.115). 3.2.8. Total Procedure Time. Five studies described total 3.2.5. Access Time. Six studies described access time. *e procedure time. *e meta-analysis showed the total pro- meta-analysis showed compared with cTRA, the access time cedure time was similar between dTRA and cTRA, with no was longer in dTRA, with the statistical difference between statistical significance (SMD �0.23, 95CI [−0.21, 0.68], 2 2 studies (SMD �0.32, 95CI [0.08, 0.56], P � 0.008;I �86.7%, P � 0.308; I �91.8%, P<0.001) (see Figure 9). We con- P<0.001) (see Figure 6). We conducted a sensitivity analysis ducted a sensitivity analysis by removing the outlier study, by removing the outlier study, heterogeneity was signifi- heterogeneity was significantly reduced after excluding the cantly reduced after excluding the study by Wang [22], and study by Bhambhani [11], and there was still no statistical there was still a statistical difference (SMD �0.41, 95CI [0.29, difference (SMD � −0.03, 95CI [−0.17, 0.11], P � 0.642; 2 2 0.54], P<0.001; I �32.5%, P � 0.205). *e Egger test I �13%, P � 0.328). *e Egger test showed no publication showed no publication bias among the studies (P � 0.463). bias among the studies (P � 0.398). 3.2.6.FluoroscopyTime. Four studies described fluoroscopy 3.2.9. Hemostatic Device Removal Time. *ree studies de- time. *e meta-analysis showed compared with cTRA, the scribed hemostatic device removal time. *e meta-analysis fluoroscopy time was longer in dTRA, with the statistical showed compared with cTRA, the hemostatic device re- difference between studies (SMD �0.16, 95CI [−0.00, 0.33], moval time was shorter in dTRA, with the statistical dif- P � 0.05;I �0.0%, P � 0.920) (see Figure 7). *e Egger test ference between studies (WMD � −66.62min, 95CI [−76.68, showed no publication bias among the studies (P � 0.246). −56.56], P<0.001; I �55.7%, P � 0.105) (see Figure 10). Eligibility Identification Included Screening 4 Journal of Interventional Cardiology Table 1: Basic information of the included studies. Diabetes Male Overall Hypertension Smoking Hyperlipidemia Jadad Author Year Country Study type Sample mellitus BMI Indicators NOS score (%) age (%) (%) (%) score (%) 408 (202 64.9 69.2 37.6 33.3 26.5 Aoi [9] 2019 USA Retrospective 85.6 vs.95.1 83.7 vs.91.7 1, 2, 3, 5, 9 7 (3/2/2) — vs. 206) vs.62.6 vs.68.8 vs.45.6 vs.25.2 vs.27.1 100 (50 Amin [10] 2017 Bangladesh Prospective — — — — — — — 1, 2, 4 7 (4/0/3) — vs.50) Bhambhani 200 (100 84 54.6 2020 India Prospective 59 vs.50 40 vs.35 39 vs.32 — — 1, 5, 6, 7, 8 9 (4/2/3) — [11] vs.100) vs.73 vs.54.9 Coughlan 94 (47 83 61 2018 Ireland Prospective — — — — — 6, 7, 8, 9 9 (4/2/3) — [12] vs.47) vs.74.5 vs.61.8 164 (82 58.5 57.7 25.6 43.9 Gajurel [13] 2018 Nepal Prospective 35.3 vs.29.2 20.7 vs.12.1 — 1, 2, 3 9 (4/2/3) — vs.82) vs.53.6 vs.57.2 vs.18.2 vs.32.9 Hammami 177 (82 62 59.23 2021 Tunisia Prospective 40 vs.44 45 vs.40 41.5 vs.42 — — 1, 3, 4 9 (4/2/3) — [14] vs. 95) vs.70 vs.60.38 41 (17 70.6 47.1 35.3 Kis [15] 2020 Turkey Prospective — 70.6 vs.79.2 41.2 vs.37.5 — 2, 3 9 (4/2/3) — vs.24) vs.70.8 vs.33.3 vs.29.2 Kaledin [16] 2017 Russia Prospective (2775 — — — — — — — 1 7 (4/0/3) — vs.3099) Koutouzis 200 (100 74 63.8 28.6 1, 2, 3, 4, 5, 3 (2/0/ 2019 Greece Randomized 73 vs.63 27 vs.28 35 vs.28 71 vs.59 — [17] vs.100) vs.77 vs.62.8 vs.29 6, 7, 8 1) 900 (450 45.56 55.28 10.67 27.56 24.06 3 (2/0/ Lin [18] 2020 China Randomized 24.89 vs.25.11 — 1, 2, 4, 5, 9 — vs.450) vs.50 vs.58.81 vs.12.44 vs.22.44 vs.24.36 1) 80 (40 57.5 54.3 Lu [19] 2020 China Prospective — 15 vs.17.5 — — — 1, 2, 4 8 (4/2/2) — vs.40) vs.62.5 vs.56.4 Roghani- 74.2 67.1 28.4 126 (70 62.8 55.1 Dehkordi 2020 Iran Prospective 57.1 vs.67.8 31.4 vs.28.6 1, 5, 6, 8 9 (4/2/3) — vs.56) vs.64.3 vs.56.5 vs.80.3 vs.78.6 vs.27.2 [20] 70 (27 63 40.7 33.3 Soydan [21] 2021 Turkey Prospective — 77.8 vs.76.7 48.1 vs.30.2 — 4 9 (4/2/3) — vs.43) vs.72.1 vs.39.5 vs.27.9 620 (312 51.3 50.1 31.4 56.4 1, 2, 3, 4, 5, Wang [22] 2020 China Prospective 60.6 vs.56.5 44.2 vs.41.9 — 8 (4/2/2) — vs.308) vs.51 vs.51.2 vs.28.2 vs.54.5 8 1- Catheterization/puncture failure; 2- hematoma; 3- radial artery spasm; 4- radial artery occlusion; 5- access time; 6- fluoroscopy time; 7- radiation dose area product; 8- total procedure time; 9- hemostatic device removal time. Journal of Interventional Cardiology 5 Study ID OR (95% CI) Weight (%) Aoi 0.81 (0.21, 3.07) 9.27 Bhambhani 9.12 (2.63, 31.59) 9.69 Hammami 2.38 (0.43, 13.37) 7.50 Koutouzis 21.00 (4.86, 90.77) 8.63 Lin 1.21 (0.60, 2.43) 12.36 Lu 15.26 (0.83, 280.72) 4.01 Roghani−Dehkordi 2.28 (0.58, 9.03) 9.04 Wang 1.23 (0.58, 2.60) 12.12 Amin 1.00 (0.14, 7.39) 6.45 Gajurel 0.66 (0.11, 4.05) 7.13 Kaledin 0.63 (0.47, 0.85) 13.79 Overall (I = 78.5%, p = 0.000) 1.94 (0.97, 3.86) 100.00 Note: weights are from random effects analysis 0.00356 1 281 (a) −2 0 2 4 6 8 Precision Study Regression line 95% CI for intercept (b) Filled funnel plot with pseudo 95% confidence limits −2 0 0.5 1 1.5 s.e. of: theta, filled (c) Figure 2: (a) Forest plot of catheterization/puncture failure for dTRA compared to cTRA. (b) Egger test was used to quantitatively assess publication bias in catheterization/puncture failure (P � 0.015). (c) Trim and fill funnel plot showed that no new studies were added. SND of effect estimate eta, filled 6 Journal of Interventional Cardiology Study ID OR (95% CI) Weight (%) Aoi 1.44 (0.45, 4.62) 24.33 Kis 0.26 (0.01, 5.71) 3.43 Koutouzis 1.00 (0.06, 16.21) 4.25 Lin 1.38 (0.55, 3.47) 38.95 Lu 0.33 (0.01, 8.22) 3.16 Wang 0.79 (0.21, 2.96) 18.81 Amin 0.19 (0.01, 4.10) 3.52 Gajurel 0.20 (0.01, 4.13) 3.54 Overall (I = 0.0%, p = 0.733) 0.97 (0.55, 1.73) 100.00 0.00899 1 111 (a) −2 0 0.5 1 1.5 2 Precision Study Regression line 95% CI for intercept (b) Filled funnel plot with pseudo 95% confidence limits −2 −4 0 0.5 1 1.5 2 s.e. of: theta, filled (c) Figure 3: (a) Forest plot of hematoma for dTRA compared to cTRA. (b) Egger test was used to quantitatively assess publication bias in hematoma (P � 0.004). (c) Trim and fill funnel plot showed that no new studies were added. SND of effect estimate Theta, filled Journal of Interventional Cardiology 7 Study ID OR (95% CI) Weight (%) Aoi 5.15 (0.25, 107.93) 3.63 Hammami 0.71 (0.22, 2.25) 25.03 Kis 0.45 (0.02, 11.66) 3.16 Koutouzis 0.74 (0.16, 3.41) 14.48 Wang 0.73 (0.30, 1.76) 43.50 Gajurel 0.66 (0.11, 4.05) 10.19 Overall (I = 0.0%, p = 0.893) 0.76 (0.43, 1.36) 100.00 0.00927 1 108 Figure 4: Forest plot of radial artery spasm for dTRA compared to cTRA. Study ID OR (95% CI) Weight (%) Hammami 0.16 (0.01, 3.15) 3.16 Koutouzis 0.53 (0.17, 1.65) 21.92 Lin 0.40 (0.17, 0.98) 35.36 Lu 0.33 (0.01, 8.22) 2.68 Soydan 0.30 (0.01, 6.53) 2.96 Wang 0.36 (0.14, 0.93) 30.92 Amin 0.19 (0.01, 4.10) 2.99 Overall (I = 0.0%, p = 0.989) 0.39 (0.23, 0.66) 100.00 0.00815 1 123 Figure 5: Forest plot of radial artery occlusion for dTRA compared to cTRA. We conducted a sensitivity analysis by removing the outlier spasm, total procedure time, or radiation dose area product, study, heterogeneity was significantly reduced after ex- but dTRA had a lower incidence of RAO, shorter hemostatic cluding the study by Lin [18], and there was still a statistical device removal time, and longer access time and fluoroscopy difference (WMD � −72.83min, 95CI [−82.39, −63.27], time than cTRA. P<0.001; I �0.0%, P � 0.656). *e Egger test showed no *e anatomical snuffbox is a triangular depression of the publication bias among the studies (P � 0.588). tip towards the thumb when the thumb is fully extended. *e radial artery in the anatomical snuffbox is superficially lo- cated and can be palpated [23]. *e vascular diameter of the 4. Discussion distal radial artery in the anatomical snuffbox is usually smaller than that of the radial artery at the wrist, with a ratio *is work aimed to evaluate the differences between dTRA of about 0.8–0.9 [24], while the diameter of the distal radial in anatomical snuffbox versus cTRA. Our meta-analysis of artery in men is larger than that in women [25], which means the 14 included studies found no significant differences in that successful distal radial artery catheterization/puncture catheterization/puncture failure, hematoma, radial artery 8 Journal of Interventional Cardiology Study ID SMD (95% CI) Weight (%) Aoi 0.43 (0.23, 0.62) 17.80 Bhambhani 0.57 (0.26, 0.88) 15.13 Koutouzis 0.61 (0.33, 0.90) 15.74 Lin 0.33 (0.19, 0.46) 19.06 Roghani−Dehkordi 0.18 (−0.19, 0.55) 13.68 Wang −0.13 (−0.29, 0.02) 18.59 Overall (I = 86.7%, p = 0.000) 0.32 (0.08, 0.56) 100.00 Note: weights are from random effects analysis −0.895 0 0.895 Figure 6: Forest plot of access time for dTRA compared to cTRA. Study ID SMD (95% CI) Weight (%) Bhambhani 0.13 (−0.17, 0.43) 29.26 Coughlan 0.18 (−0.22, 0.59) 16.29 Koutouzis 0.12 (−0.16, 0.40) 34.74 Roghani−Dehkordi 0.27 (−0.10, 0.64) 19.71 Overall (I = 0.0%, p = 0.920) 0.16 (−0.00, 0.33) 100.00 −0.642 0 0.642 Figure 7: Forest plot of fluoroscopy time for dTRA compared to cTRA. Study ID WMD (95% CI) Weight (%) Bhambhani 1349.70 (−762.97, 3462.37) 2.64 Coughlan 206.66 (−912.53, 1325.85) 9.40 Koutouzis 184.00 (−181.84, 549.84) 87.96 Overall (I = 0.0%, p = 0.567) 216.88 (−126.24, 560.00) 100.00 −3462 0 3462 Figure 8: Forest plot of radiation dose area product for dTRA compared to cTRA. Journal of Interventional Cardiology 9 Study ID SMD (95% CI) Weight (%) Bhambhani 1.15 (0.83, 1.48) 19.85 Coughlan −0.11 (−0.52, 0.29) 18.78 Koutouzis 0.13 (−0.14, 0.41) 20.45 Roghani−Dehkordi 0.12 (−0.25, 0.49) 19.31 Wang −0.12 (−0.28, 0.03) 21.61 Overall (I = 91.8%, p = 0.000) 0.23 (−0.21, 0.68) 100.00 Note: weights are from random effects analysis −1.48 0 1.48 Figure 9: Forest plot of total procedure time for dTRA compared to cTRA. Study ID WMD (95% CI) Weight (%) Aoi −74.00 (−84.85, −63.15) 35.82 Coughlan −68.80 (−88.98, −48.62) 17.69 Lin −60.10 (−67.38, −52.82) 46.49 Overall (I = 55.7%, p = 0.105) −66.62 (−76.68, −56.56) 100.00 Note: weights are from random effects analysis −89 0 89 Figure 10: Forest plot of hemostatic device removal time for dTRA compared to cTRA. seems to be more challenging. *e overall catheterization/ the terminal of the radial artery forms the deep palmar arch puncture failure of dTRA included in this meta-analysis was at the distal end of the anatomical snuffbox with the deep higher than that of cTRA, but there was no statistically palmar branch of the ulnar artery. *ere are abundant significant difference (4.3% VS 3.8%, P>0.05), and the collateral anastomoses between the two arches. Even if the access time was prolonged in dTRA, but did not affect total distal radial artery is occluded, antegrade flow is maintained procedure time. Bhambhani [11] performed distal radial and the risk of retrograde thrombosis is reduced [23, 28, 29]. artery cannulation in 100 patients and found access time in *is meta-analysis found that compared with cTRA, he- dTRA was progressively reduced, from 5.89 minutes in the mostatic device removal time was shorter in dTRA (WMD � −66.62min, 95CI [−76.68, −56.56], P<0.001), the first 25 cases to 2.47 minutes in the last 25 cases. Also, Lee [26] found that puncture time stabilized after approximately incidence of radial artery occlusion was lower in dTRA 150 distal radial artery punctures had been performed. (4.6% vs 1.7%, P<0.001), and the incidence of hematoma *erefore, the learning curve must be overcome to master (2.1% vs 1.8%, P � 0.926) and radial artery spasm (3.4% vs the dTRA. 2.6%, P � 0.354) was similar in dTRA, suggesting that the *e anatomical snuffbox is surrounded by soft tissue and dTRA was more comfortable and safer for patients. has a bony base consisting of the scaphoid bone and tra- When performing the left dTRA, the patient can nat- pezium bone, which can be easily compressed to hemostasis, urally place the left hand at the level of the right groin, and the complications of bleeding and hematomas are allowing the operator on the right side of the patient to not uncommon [23, 27]. *e radial artery divides into the su- bend over. *is allows the operator to keep away from the perficial palmar branch near the level of the AS to form the source of radiation and avoid high radiation doses and solve the problem of postoperative restriction of the right hand, superficial palmar arch with the terminal ulnar artery, and 10 Journal of Interventional Cardiology which is extremely comfortable for right-handed patients Acknowledgments [4]. *is meta-analysis found no significant difference in *is work was supported by special projects for the Guid- radiation dose area product between dTRA and cTRA ance of the Transformation of Scientific and Technological (P � 0.215), but the fluoroscopy time in dTRA was pro- Achievements in Shanxi Province (Project no. longed (P � 0.05). As P � 0.05 represents the critical P 201804D131045) and the Transformation and Cultivation value, which is at the borderline of statistical significance, Projects of Scientific and Technological Achievements in this result should be interpreted with more caution and Colleges and Universities of Shanxi Province (Project no. needs to be further demonstrated in large-sample studies. 2020CG028). Despite the advantages of shorter hemostatic device removal time and lower incidence of RAO, the limitations of this novel access should be noted: smaller vascular diameter Supplementary Materials limits the use of large bore sheaths, and longer access time may delay coronary revascularization, especially in cases of Online supplementary file 1: search strategies. (Supple- myocardial infarction. mentary Materials) *ere are some limitations in this meta-analysis. First, publication bias was present in the catheterization/puncture References failure and hematoma. 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