Lower Patient Height and Weight Are Predisposing Factors for Complex Radial Arterial Catheterization
, Se-Chan Kim 2,‡ and Tobias Hilbert 1,*,‡
Arnold H. Seto
Round 1
Reviewer 1 Report
The authors present their small study of 41 patients with ultrasound identification of small radial arteries, and find that lower height and BMI are associated with smaller radial arteries and more difficulty with transradial access afterwards. Their methods are good, with the exception of the very small size of their study. They utilized blinded ultrasound prior to the planned access which is quite rigorous. Their conclusions are reasonable and their presentation/writing is not perfect it is understandable.
I would suggest considering adding the following references and discussion:
Roberts, J Invasive Cardiology 2023 Jan 26;JIC20230126-2.
Seto, JACC Interventions 2015 Feb;8(2):283-291
Author Response
Reviewer #1:
I would suggest considering adding the following references and discussion:
Roberts, J Invasive Cardiology 2023 Jan 26;JIC20230126-2.
Seto, JACC Interventions 2015 Feb;8(2):283-291
We thank the Reviewer for this valuable input. As suggested, we now added the references to the works from Roberts and Niu and from Seto et al. to the Discussion section of our manuscript, thereby improving the interpretation of our results.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
I have read with pleasure this manuscript about a study that investigates a topic already known (unfortunately) in the interventional cardiology community. There are plenty of studies out there already with the same (logical) findings that smaller radial artery diameters are associated with smaller bodies and more difficult cannulation. Nevertheless, the study is well conducted, easy to comprehend, and in fact addresses a different field and community, the anesthesiologists who need to access this artery as well, for invasive blood pressure monitoring reasons. I would have some suggestions that could improve your paper:
- Brief Report format fits very well
- The abstract is clear, you get the essence just by reading it.
- Methods: radial artery procedural success is dependent on the operator's expertise. You need to state how many physicians did perform radial access and what their expertise/experience was. You may also need to mention that the same operators performed all patients across the two groups uniformly (if the case).
- Methods: you do not state the location where the operators performed radial access. You may not be aware of the current distinction between proximal radial access (conventional, traditional one - and where most probably you performed the puncture) and distal radial access (which is a newer access, also used in anesthesiology now). So maybe after the phrase "The puncture itself was performed either without or primarily or secondarily using ultrasound guidance at the discretion of the operator who was not part of the..." you may add a phrase "The puncture was performed at the level of proximal radial in all cases, approximately 2 cm proximal to the radial styloid (to be differentiated with the distal radial access which is performed at the level of the snuffbox)". Or any phrase like this. It's important because now we have 2 locations for radial access.
- Results: to the phrase "As shown in Figure 1B, distal as well as proximal 136 internal radial artery diameter was significantly smaller in group 2 patients (difficult catheterization), compared to group 1 patients." please add the P value in the text.
- Discussion: As previously discussed, please mention the alternative distal radial access which was also proven to be non-inferior compared to the conventional proximal radial access: https://doi.org/10.1186/s12871-022-01609-5; exactly like in your study, ultrasound brings a benefit, there is a nice pictorial recent review about this technique, it would be nice to cite it: https://doi.org/10.3390/life13010025
- Interestingly, in your study, the quality of the radial artery (plaques, stenoses) did not influence the access. Put a phrase here on maybe why? (not severely affected arteries typically found in heavy smokers or dialysis patients?) A recent and interesting study showed in fact that radial calcification was correlated with coronary calcification and coronary plaque burden that required revascularization. Add maybe another phrase that ultrasound may be useful also in this manner, you could in fact screen patients with severe calcifications that may have similar deposits in other important arterial systems. Please cite: https://doi.org/10.1155/2022/5108389
- Limitation: you need to state that your study population was small and that your conclusions may be underpowered by this.
- Conclusion: you need to add one.
Author Response
Reviewer #2:
Methods: radial artery procedural success is dependent on the operator's expertise. You need to state how many physicians did perform radial access and what their expertise/experience was. You may also need to mention that the same operators performed all patients across the two groups uniformly (if the case).
The Reviewer is absolutely right with this, and we apologize for not being precise enough here. All catheterizations in both groups were performed uniformly by the same three operators all of which were board-certified anesthesiologists with years of experience in performing arterial and venous vascular punctures. This detail has now been added to the Methods and the Discussion section.
Methods: you do not state the location where the operators performed radial access. You may not be aware of the current distinction between proximal radial access (conventional, traditional one - and where most probably you performed the puncture) and distal radial access (which is a newer access, also used in anesthesiology now). So maybe after the phrase "The puncture itself was performed either without or primarily or secondarily using ultrasound guidance at the discretion of the operator who was not part of the..." you may add a phrase "The puncture was performed at the level of proximal radial in all cases, approximately 2 cm proximal to the radial styloid (to be differentiated with the distal radial access which is performed at the level of the snuffbox)". Or any phrase like this. It's important because now we have 2 locations for radial access.
We again want to apologize for being imprecise here. We now added details to the approach, stating that the puncture was performed at the level of the proximal radial artery in all cases, approximately 2 cm proximal to the radial styloid (to be differentiated with the distal radial access which is performed at the level of the snuffbox). Moreover, as requested by the Reviewer, the also existing alternative distal radial access is now mentioned in the Discussion section of the manuscript, together with the respective reference from Xiong et al.1
Results: to the phrase "As shown in Figure 1B, distal as well as proximal 136 internal radial artery diameter was significantly smaller in group 2 patients (difficult catheterization), compared to group 1 patients." please add the P value in the text.
The P value has now been added to the text (p = 0.02).
Discussion: As previously discussed, please mention the alternative distal radial access which was also proven to be non-inferior compared to the conventional proximal radial access: https://doi.org/10.1186/s12871-022-01609-5; exactly like in your study, ultrasound brings a benefit, there is a nice pictorial recent review about this technique, it would be nice to cite it: https://doi.org/10.3390/life13010025.
As requested by the Reviewer, the alternative distal radial access is now mentioned in the Discussion section of the manuscript, together with the respective reference from Xiong et al.1 Furthermore, positive results describing the use of ultrasound in alternative radial access routes such as the distal approach performed at the level of the snuffbox with reduced complications and maximized technical success even in small-diameter or pathological arteries are now also mentioned, together with the reference to the recent pictorial review from Achim et al.2
Interestingly, in your study, the quality of the radial artery (plaques, stenoses) did not influence the access. Put a phrase here on maybe why? (not severely affected arteries typically found in heavy smokers or dialysis patients?) A recent and interesting study showed in fact that radial calcification was correlated with coronary calcification and coronary plaque burden that required revascularization. Add maybe another phrase that ultrasound may be useful also in this manner, you could in fact screen patients with severe calcifications that may have similar deposits in other important arterial systems. Please cite: https://doi.org/10.1155/2022/5108389.
This is a very interesting fact, and we greatly appreciate the Reviewer’s input. In fact, in our study, plaques and stenoses were equally distributed among the two groups, suggesting that radial artery quality has no impact on catheterization success. As revealed by a large study from Dehghani et al. involving more than 2,000 patients, neither plaques nor stenoses were independently associated with failing transradial cannulation for percutaneous coronary intervention.3 However, due to the restricted sample size of our observation, an influence may not be excluded with ultimate certainty. We added this information to the manuscript. We now also refer to the recent study from Achim et al. that revealed this further interesting aspect by demonstrating that radial artery calcification correlates with coronary calcification and plaque burden requiring revascularization.4 In our opinion, this suggests that radial ultrasound may also be useful to identify patients with significant coronary atherosclerosis preoperatively, underlining the role of the anesthesiologist to screen for relevant comorbidities.
Limitation: you need to state that your study population was small and that your conclusions may be underpowered by this.
As suggested, these limitations were added to the respective section.
Conclusion: you need to add one.
Finally, we now present a concluding remark at the end of our manuscript, hoping to meet the Reviewer’s demands.
References:
- Xiong, J. et al. Distal radial artery as an alternative approach to forearm radial artery for perioperative blood pressure monitoring: a randomized, controlled, noninferiority trial. BMC Anesthesiol. 22, 67 (2022).
- Achim, A. et al. The Role of Ultrasound in Accessing the Distal Radial Artery at the Anatomical Snuffbox for Cardiovascular Interventions. Life 13, 25 (2023).
- Dehghani, P. et al. Mechanism and predictors of failed transradial approach for percutaneous coronary interventions. JACC Cardiovasc. Interv. 2, 1057–1064 (2009).
- Achim, A. et al. Radial Artery Calcification in Predicting Coronary Calcification and Atherosclerosis Burden. Res. Pract. 2022, e5108389 (2022).
Author Response File: Author Response.pdf
