Optimizing distal radial access: clinical and anatomical predictors of failure from the multicenter DISTAL registry.

Background: Distal radial access (DRA) is a promising alternative to conventional transradial access for coronary procedures, offering fewer vascular complications, shorter hemostasis, and greater patient comfort. However, the predictors of DRA failure remain insufficiently defined. This study aimed to evaluate the feasibility, safety, and predictors of DRA failure in an all-comer population and to develop an evidence-based strategy to optimize procedural success.

Methods: A prospective multicenter cohort included 1387 patients who underwent 1454 coronary procedures through DRA between August 2020 and September 2024. Multivariate logistic regression and conditional inference trees (CITs) were used to identify and visualize independent predictors of failure.

Results: DRA was successful in 96.5% of cases, with 99% of coronary procedures completed through the initial access. Access-related complications were infrequent (2.5%), including 0.8% inhospital radial artery occlusion. Weak distal radial pulse was the strongest independent predictor of failure (odds ratio: 10.07, 95% confidence interval: 5.22-20.21; P  < 0.001), while preprocedural ultrasound (US) evaluation, US-guided puncture, right-sided access, and operator experience independently predicted success. US guidance markedly improved outcomes in patients with weak pulses (98.2% vs. 61.0%; P  < 0.001). The learning curve plateaued after 60 cases.

Conclusion: DRA is a safe, feasible, and effective access strategy for coronary procedures in an all-comer population. The success of the procedure depends on the strength of the arterial pulse, the US guidance, and the experience of the operator. The CIT-derived evidence-based framework provides a practical and reproducible approach to optimize access-site selection and improve procedural outcomes.