Efficacy and safety of distal radial approach for cardiac catheterization: A systematic review and meta-analysis

Table 1 Summary of the characteristics of the eligible studies

Ref.	Country	Subject No.	Mean age in yr	Male, %	Right arm/left arm, n	CAG/PCI (n)	5-Fr sheath/6-Fr sheath, n	Operators	Medications to prevent radial artery spasm	Approach to hemostasis	Timing of assessment of radial artery occlusion
Mokbel et al[26], 2018	Romania	200	63.4	NS	NS	NS	NS	NS	Nitrate	NS	At discharge
Koutouzis et al[25], 2019	Greece	205	63.3	75.5	152/48	200/0	0/200	Specialists	Verapamil	Manual compression	At discharge
Vefalı et al[16], 2020	Turkey	114	60.4	69.3	33/172	156/49	205/0	NS	NS	Manual compression	NS

CAG: Coronary angiography; NS: Not stated; PCI: Percutaneous coronary intervention.

Table 2 Quality scores for the studies eligible for the evaluation of the successful cannulation rate

Ref.	Risk of bias 2 tool assessment
	Bias arising from the randomization process	Bias due to deviations from intended interventions	Bias due to missing outcome data	Bias in measurement of the outcome	Bias in selection of the reported results	Overall risk of bias
Mokbel et al[26]	Some concerns	Low	Low	Low	Some concerns	Some concerns
Koutouzis et al[25]	Low	Low	Low	Low	Some concerns	Some concerns
Vefalı et al[16]	Some concerns	Low	Low	Low	Some concerns	Some concerns

Table 3 Summary of findings (the efficacy and safety of the radial approach vs the distal radial approach for diagnostic coronary angiography and percutaneous coronary intervention)

Patient or population: Adults; Setting: Diagnostic coronary angiography and percutaneous coronary intervention; Intervention: Radial approach (RA); Comparison: Distal radial approach (DRA)
Outcomes	Anticipated absolute effects1 (95%CI)		Relative effect (95%CI)	Patient number (studies)	Certainty of the evidence, GRADE	Comments
	Risk with RA	Risk with DRA
Successful cannulation rates	950 per 1000	798 per 1000 (532-1000)	RR 0.90 [0.72-1.13]	519 (3 RCTs)	Low2,3	DRA resulted in little to no difference in successful cannulation rates
Radial artery spasm	39 per 1000	16 per 1000 (4-56)	RR 0.43 [0.08-2.49]	405 (2 RCTs)	Low3	DRA may reduce incidence of radial artery spasm
Radial artery occlusion	32 per 1000	14 per 1000 (5-41)	RR 0.48 [0.18-1.29]	314 (2 RCTs)	Low3	DRA may reduce the incidence of radial artery occlusion
Mean number of punctures per patient	The mean number of punctures per patient were 2.4 in DRA in comparison to 1.6 in RA			200 (1 RCT)	Low3	DRA may reduce the mean number of punctures per patient
Mean time for hemostasis	-	MD 6.64 min lower (10.37 lower to 2.9 lower)	-	405 (2 RCTs)	Very low2,3,4	DRA reduced mean time for hemostasis

¹The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% confidence interval). GRADE Working Group grades of evidence: High certainty: Very confident that the true effect lies close to that of the estimated effect. Moderate certainty: Moderately confident in the estimated effect. The true effect is likely to be close to the estimated effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the estimated effect is limited: The true effect may be substantially different from the estimated effect. Very low certainty: We have very little confidence in the estimated effect. The true effect is likely to be substantially different from the estimated effect.

²Downgraded because of inconsistency due to substantial heterogeneity.

³Downgraded because of imprecision due to small sample size and/or small number of participants.

⁴Downgraded due to imprecision because of high risk of bias.

CI: Confidence interval; MD: Mean difference; RCT: Randomized-controlled trial.