794 Letters JACC: CARDIOVASCULAR INTERVENTIONS VOL. 15, NO.

7, 2022
APRIL 11, 2022:793–796

(Physiologic Assessment of Coronary Stenosis REFERENCE

Following PCI) study according to post-PCI instanta- 1. Patel M, Jeremias A, Maehara A, et al. 1-Year outcomes of blinded physi-
neous wave-free ratio (iFR) values are consistent after ological assessment of residual ischemia after successful PCI: DEFINE PCI trial.
J Am Coll Cardiol Intv. 2022;15(1):52–61.
PCI in the left anterior descending coronary artery
(LAD) and non-LAD territories.1 As an observational
pilot study in only 500 patients, the modest number
TO THE EDITOR
of 1-year events that accrued limits the utility of
subgroup analyses. As in most prior studies, adverse Distal Transradial
event rates tended to be higher after PCI in the LAD
compared with non-LAD vessels.
Access for Primary PCI
Unfortunately, the number of events limits the in ST-Segment Elevation
power to reliably examine the vessel-specific re-
lationships between post-PCI iFR and outcomes.
Myocardial Infarction
These data, as well as the event curves stratified for
LAD and non-LAD territories, will be reported in an We read with great interest the paper by Tsigkas
upcoming paper. The ongoing large-scale randomized et al,1 as well as its related editorial comment by
DEFINE GPS (Distal Evaluation of Functional Perfor- Valgimigli et al,2 published in JACC: Cardiovascular
mance With Intravascular Sensors to Assess the Nar- Interventions, regarding the randomized ANGIE
rowing Effect: Guided Physiologic Stenting) trial (Anatomical sNuffbox for coronary anGiography and
evaluating the hypothesis that achieving post-PCI IntervEntions) trial. This single-center, larger thus
iFR $0.95 will reduce adverse clinical outcomes (in far physician-initiated trial of 1,042 consecutive
both LAD and non-LAD vessels) will be essential in patients undergoing coronary angiography and/or
answering the issues addressed in this thoughtful percutaneous coronary interventions (PCI), which
letter. compared the efficacy and the safety of right distal
transradial access (dTRA) or the right conventional
*Manesh R. Patel, MD
transradial access (cTRA), reported that dTRA was
Allen Jeremias, MD, MSc
associated with a significantly 2-fold lower risk of
Akiko Maehara, MD
forearm radial artery occlusion (RAO) by Doppler
Gregg W. Stone, MD
ultrasound at 60 days.1
*Duke Clinical Research Institute
The investigators are to be congratulated on
Duke University Medical Center
providing important and incremental data corrobo-
2301 Erwin Road
rating the lower rates of forearm RAO and its poten-
Hafs Building, Room 8695
tial benefits that follow. 1,3 Nevertheless, dTRA was
Durham, North Carolina 27710, USA
associated with 4-fold higher rate of access site
E-mail: manesh.patel@duke.edu
crossover (21.8% vs 5.5%), mainly due to failure to
https://doi.org/10.1016/j.jcin.2022.02.040
insert the sheath’s wire, longer access and
Ó 2022 by the American College of Cardiology Foundation. Published by Elsevier.
procedural times (dTRA vs cTRA: 120 vs 75 seconds
Dr Patel has received research grants from Bayer, Janssen, Amgen, Novartis, the
and 14 vs 11 minutes, respectively) as well as higher
National Heart, Lung, and Blood Institute, Phillips, and HeartFlow; and is an
advisory board member for Bayer, Janssen, and HeartFlow. Dr Jeremias has radiation dose–area product by w10%.1 Yet concerns
received institutional funding (unrestricted education grant) from Philips/Vol-
have been raised about all these aforementioned
cano; and is a consultant for Philips/Volcano, Abbott Vascular, Acist Medical,
and Boston Scientific. Dr Maehara is a consultant for Boston Scientific, Philips, limitations 2 with dTRA if extrapolated to patients
and Shockwave. Dr Stone has received speaker honoraria from Pulnovo and
with ST-segment elevation myocardial infarction
Infraredx; is a consultant to Valfix, TherOx, Robocath, HeartFlow, Ablative So-
lutions, Vectorious, Miracor, Neovasc, Abiomed, Ancora, Elucid Bio, Occlutech, (STEMI) undergoing primary PCI, which should be
CorFlow, Apollo Therapeutics, Impulse Dynamics, Vascular Dynamics, Shock-
performed in a timely-fashion and by experienced
wave, V-Wave, Cardiomech, Gore, and Amgen; holds equity and options in
Ancora, Cagent, Applied Therapeutics, the Biostar family of funds, Spec- operators.
traWave, Orchestra Biomed, Aria, Cardiac Success, Valfix, and Xenter; has
What is the real impact and how can these limita-
received research support to his employer (Mount Sinai Hospital) from Abbott,
Bioventrix, Cardiovascular Systems, Phillips, Biosense Webster, Shockwave, tions be overcome so that the dTRA can also be
Vascular Dynamics, and V-wave; and has a family member (daughter) who is an
applied to patients with STEMI? As previously
employee of Medtronic.
The authors attest they are in compliance with human studies committees and observed with cTRA: 1) operators’ expertise and pro-
animal welfare regulations of the authors’ institutions and Food and Drug
ficiency lie on adequate familiarity with the nuances
Administration guidelines, including patient consent where appropriate. For
more information, visit the Author Center. of this more challenging access site; 2) Doppler
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 15, NO. 7, 2022 Letters 795
APRIL 11, 2022:793–796

ultrasound guidance for improving arterial puncture REFERENCES

success, especially during the learning curve, should
be encouraged; and 3) a standardized cath lab proto-
col, from optimal patient positioning until adequate
hemostasis, should be established. Indeed, the in-
vestigators of the ANGIE trial noted a reduction of the
crossover rates over quartiles of study time with right
dTRA (from 26.2% to 16.4%). 1
In our initial experience in the DISTRACTION
1. Tsigkas G, Papageorgiou A, Moulias A, et al. Distal or traditional transradial
access site for coronary procedures: a single-center, randomized study. J Am
Coll Cardiol Intv. 2022;15:22–32.
2. Valgimigli M, Landi A. Distal transradial access for coronary procedures: old
certainties, novel challenges, and future horizons. J Am Coll Cardiol Intv.
2022;15(1):33–38.
3. Eid-Lidt G, Rivera Rodríguez A, Jimenez Castellanos J, Farjat Pasos JI,
Estrada López KE, Gaspar J. Distal radial artery approach to prevent
radial artery occlusion trial. J Am Coll Cardiol Intv. 2021;14(4):378–385.

(DIStal TRAnsradial access as default approach for

Coronary angiography and intervenTIONs) prospec- REPLY: Distal Transradial Access for
tive cohort registry (ensaiosclinicos.gov.br Identifier: Primary PCI in ST-Segment Elevation
RBR-7nzxkm), among 3,700 consecutive patients Myocardial Infarction
undergoing dTRA coronary angiography, 849 patients
We would like to thank Drs Oliveira and Caixeta for
(22.9%) had STEMI. Among all 849 STEMI patients,
their valuable comments on our study.1 We showed
there were 17 (2%) access site crossovers (failure to
that the distal transradial artery (dTRA) strategy is
insert the sheath’s wire), 4 of those successfully
associated with a lower rate of radial artery
executed by contralateral dTRA. No access site–
occlusion and a shorter time of hemostasis
related significant bleeding/hematoma and no hand/
compared with transradial artery (TRA) access in
thumb dysfunction after any procedure were docu-
patients without ST-segment elevation myocardial
mented. Of note, due to logistic reasons, time to
infarction (STEMI). 2 It remains to be proved in a
dTRA, crossover access site attainment, as well as
prospective randomized study if this strategy is also
fluoroscopy and procedural times, were not system-
superior to TRA in patients with STEMI. In such a
atically recorded. Thus, despite its retrospective na-
study, the application of the modified EASY (Early
ture and undocumented potential selection biases, it
Discharge After Transradial Stenting of Coronary
seems to us that the incorporation of dTRA for pri-
Arteries Study) score for grading forearm
mary PCI in STEMI patients appears to be feasible and
hematomas could be used. 1 A major limitation to
safe. Large and randomized trials are needed and
implementation of the dTRA strategy on an all-
expected (Comparison of Distal Transradial Access
comers basis in the setting of primary percutaneous
and Transradial Access for Primary Percutaneous
coronary intervention (PCI) may be the time delay
Coronary Intervention in STEMI Patients [RESERVE];
for gaining arterial access, leading to a relatively
NCT04861389) to evaluate the limitations and ad-
high crossover rate. 1-3 Therefore, Drs Oliveira and
vantages of this potentially disruptive technique in
Caixeta and their group should be congratulated for
such a challenging scenario.
the 2% crossover rate with the dTRA strategy in an
observational cohort of patients with STEMI, which
Marcos Danillo Oliveira, MD, MSc
*Adriano Caixeta, MD, PhD is impressive compared with published data. 1,3
We agree that Doppler ultrasound guidance could be
*Department of Interventional Cardiology
useful to achieve a higher success rate. However, this
Escola Paulista de Medicina
may also result in delays in the context of primary PCI;
Universidade Federal de São Paulo, Brazil
thus, we believe that it should be preferably applied in
Hospital Israelita Albert Einstein, São Paulo, Brazil
patients in stable condition for training purpose.
Napoleão de Barros
Needless to say, in a primary PCI setting, either in the
n 715 - Vila Clementino
context of a study or in real life, a predefined small time
São Paulo-SP, 04024-002, Brazil
interval (eg, 2 minutes) should be devoted to attempts
E-mail: acaixeta@me.com
for dTRA access, followed by a switch to TRA to
https://doi.org/10.1016/j.jcin.2022.02.021
diminish potential delays. Finally, the higher radiation
Ó 2022 by the American College of Cardiology Foundation. Published by Elsevier.
dose–area product in the dTRA compared with the TRA
The authors have reported that they have no relationships relevant to the
contents of this paper to disclose.
group in our study constitutes an intriguing
The authors attest they are in compliance with human studies committees and finding that needs further investigation
animal welfare regulations of the authors’ institutions and Food and Drug
Administration guidelines, including patient consent where appropriate. For
(NCT04403815 and NCT04023838), especially in the
more information, visit the Author Center. acute setting of primary PCI.