Vascular Access Registry (VARegistry) - Prospective Registry of Vascular Access

A. Introduction Ensuring vascular access is a prerequisite for coronary angiography and/or angioplasty (Percutaneous Coronary Intervention - PCI), and for transcatheter aortic valve replacement (TAVR). Femoral access has been the established access route for several decades regarding coronary interventions and currently for structural heart disease, mainly due to the size of the sheaths. However, due to increased vascular complications, speaking mostly for coronary interventions, alternative access routes with additional benefits have been sought. In this context, the brachial artery and the ulnar artery were tested without the expected results, while the radial artery presented the most favourable characteristics and was eventually established as the main access route. Recent guidelines from the European Heart Society (ESC), the American College of Cardiology (ACC), American Heart Association (AHA) and the Society for Cardiovascular Angiography and Interventions (SCAI) recommend the TransRadial Approach (TRA) for both acute and chronic coronary syndromes, as well as complex coronary interventions.

Recently, an alternative transradial approach through the anatomical snuffbox has been proposed. Large, randomized studies have shown that the distal TransRadial Approach (dTRA) is a safe method, with faster hemostasis time and lower rates of obstruction of the radial artery. (Radial Artery Occlusion - RAO). Initially, it was shown that dTRA reduces the rate of RAO in the forearm, compared to TRA in the first 1-30 days after intervention. Then, the lower rate of RAO in the dTRA group was confirmed, and the significantly less time required for haemostasis in the dTRA access group was highlighted. The most recent, multicenter study, DISCO-RADIAL, did not show a statistically significant advantage in avoiding RAO when using dTRA, however, it should be noted that RAO prevalence was less than 1% in both access sites.

Both studies showed a lower risk of EASY ≥II hematoma, but ANGIE study showed a statistically significant difference in the incidence of hematomas at the puncture site using a modified EASY scale. There was consensus both on the frequency of crossover of access site from dTRA, and on the longer duration required for gaining access of the dTRA.

A common point of the randomized studies that have been conducted so far is the exclusion of patients with ST-elevation myocardial infarction (STEMI), as the safety and effectiveness of the technique had to be firstly demonstrated, and when the necessary experience was acquired in more stable clinical contexts, it could then be tested in more urgent situations. Similarly, in the case of TRA, STEMI patients were the last framework in which its superiority over the femoral access was proven. Limited data exists to date on the use of dTRA in patients with STEMI, and those are derived from retrospective and prospective studies. In addition, non-randomized studies have shown that dTRA is a reliable alternative to TRA and femoral approach in the emergency setting. Nevertheless, no randomized studies have yet been published comparing dTRA with TRA in STEMI patients.

Despite the increasing use of transradial access and consequential reciprocal reduction in femoral access use for coronary angiography and PCI, femoral access remains necessary for numerous procedures, many of which require large-bore access. The transfemoral approach is the preferred and most commonly used access for transcatheter aortic valve replacement. Femoral access is used in most cases of mechanical circulatory support, such as in the setting of cardiogenic shock, cardiac arrest, or high-risk PCI with such devices as intra-aortic balloon pump, Impella (Abiomed, Danvers, Massachusetts), or venoarterial extracorporeal membrane oxygenation. Additionally, femoral access is preferred for some complex coronary interventions, such as coronary chronic total occlusion PCI.