Distal radial access for complex percutaneous coronary interventions: current evidence and future perspectives

Distal radial access (DRA) is a valid alternative to conventional transradial access (TRA) for coronary angiography and/or percutaneous coronary intervention (PCI). Increasing experience and expertise with DRA have enabled its potential use in patients undergoing PCI for more complex coronary lesions, such as chronic total occlusions, left main coronary artery disease, heavily calcified lesions, and complex bifurcation lesions. However, randomized evidence on DRA is currently limited to diagnostic procedures and/or PCI of non-complex coronary lesions, typically using ≤ 6-French (Fr) arterial sheaths or guide catheters. Data regarding the feasibility and safety of DRA for complex PCI remains restricted to small, single-center studies and multicenter registries, which have included only a limited number of patients undergoing PCI with large-bore (≥ 7-Fr) guide catheters. Despite these limitations, existing data suggest that DRA is both feasible and safe for complex PCI. However, dedicated randomized trials are needed to further substantiate these findings. The DISCO COMPLEX (NCT05490238) randomized trial is currently investigating the superiority of DRA over conventional TRA in terms of radial artery occlusion rates in patients undergoing complex large-bore PCI with a 7-Fr introducer sheath. This article reviews the current evidence and explores future directions for DRA in complex coronary interventions.