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We read with great joy the recent article by Kuhn et al entitled, “ Distal radial access in the anatomical snuffbox for neurointerventions: a feasibility, safety, and proof-of-concept study.” The authors should be congratulated on their work, as well as the use and maturation of the distal radial technique from diagnostic to interventional procedures. The authors detail their use of the Prelude sheaths which we agree are excellent low profile large lumen sheaths for radial access. We typically utilize the Glide Slender sheaths (Terumo) but both are excellent options. We also agree that the distal radial approach can be used for numerous interventions with access sizes from 4 to 6F, including 6F sheathless long 088 guides. Our choice for distal radial sheathless long 088 guides is Infinity LS (Stryker), and for 071 guides the Benchmark (penumbra) via a 6F sheath.
The authors noted their series was the first series to cover numerous neurointerventions with distal transradial access, however we would like to respectfully point out that we published on this topic in January of 2019 (accepted in March of 2019). Our paper by Rajah et al entitled, “ Snuff box radial access: A technical note on distal radial access for neuroendovascular procedures” can be found in Brain Circulation at the following citation available in PUBMED.
Rajah G, Garling RJ, Hudson M, Luqman A. Snuff box radial access: A technical note on distal radial access for neuroe...
Rajah G, Garling RJ, Hudson M, Luqman A. Snuff box radial access: A technical note on distal radial access for neuroendovascular procedures. Brain circulation. 2019 Jan;5(1):36.
Our paper details our technique, the pros of anatomic orientation of the hand for both the patient and surgeon, as well as the theoretical safety of the distal radial approach with regards to ischemia. We detail how our access is performed with ultrasound, and depict 4 illustrative case examples with imaging including aneurysm stent coiling, head and neck embolization, posterior fossa parent vessel sacrifice, and carotid stenting via a sheathless approach. We had switched over our entire practice for surgeon (AL) to distal radial access in November of 2018. Since that time all diagnostic angiograms and most interventions were performed via distal radial access including ischemic strokes. We have a distal radial manuscript currently accepted to Brain Circulation detailing our use of a Balloon guide catheter for ischemic stroke, which we admit still has its limitations with the available current guides due to outside diameter (OD) and stiffness. However with newest Balloon guides recently approved by the FDA, such as those made by Q’Apel, Medical boasting an 087 ID with a flexible design may provide for sheathless radial use. A 7F 072 balloon guide is also advertised by the Q’Apel. Kuhn et al explains distal radial access can provide enough support for flow divertor deployment intracranially, we echo this finding, as we have also treated aneurysms and carotid cavernous fistulas via a distal radial approach with flow divertors in tandem or stacked fashion.
We again applaud the authors on their work, and are excited to see the field moving toward more distal radial access during the current radial revolution in the neuro endovascular world. We agree with the authors this technique is a safe and effective way to perform a variety of endovascular procedures and should be in every surgeons armamentarium.
Gary Rajah MD
Ali Luqman MD