Distal Radial Access vs Transradial Access in Patients With ST-Segment Elevation Myocardial Infarction

BACKGROUND: Distal radial access (DRA) has emerged as an alternative to transradial access (TRA) in coronary procedures. However, evidence supporting its use in ST-segment elevation myocardial infarction (STEMI) remains limited. OBJECTIVES: The purpose of this study was to assess whether DRA is noninferior to TRA in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI. METHODS: This multicenter, open-label, randomized controlled trial was conducted at 3 centers in South Korea. Patients undergoing primary PCI for STEMI were randomly assigned to either the DRA or TRA group. The primary endpoint was the puncture success rate. A noninferiority testing with a prespecified margin of 5.65% was performed in the intention-to-treat, per-protocol, and as-treated populations (NCT03611725). RESULTS: From August 2018 to February 2023, 354 patients were randomized to DRA (n = 176) or TRA (n = 178). The primary endpoint, puncture success rate was 94.3% in DRA and 96.1% in TRA (difference -1.75%; 95% CI -6.20% to 2.71%) in the intention-to-treat analysis. The per-protocol analysis also failed to demonstrate noninferiority (difference -1.72%; 95% CI -5.99% to 2.54%). DRA demonstrated noninferiority to TRA in the as-treated population (difference -1.17%; 95% CI -5.56% to 3.22%). The rates of successful coronary angiography and PCI, access-site crossover, and bleeding complications were comparable between groups. One radial artery occlusion occurred in TRA group at 1-month follow-up. CONCLUSIONS: In STEMI patients, DRA failed to demonstrate noninferiority to TRA in terms of puncture success. However, both access routes showed comparable procedural efficacy and safety. Further validation with a larger, adequately powered study is required to confirm these findings.