Aims :To evaluate safety and efficacy of distal right radial access (DRRA) compared to right radial access (RRA), for coronary procedures, in patients with smaller diameter radial arteries (SDRA) (radial artery diameter (RAD) < 2.1 mm). Methods and results This is a retrospective analysis of safety and efficacy of DRRA Vs. RRA in patients undergoing coronary procedures at our cardiac catheterization laboratories over a 10- month period between September 2017 and June, 2018 (first 5 calendar months with RRA-first; next 5 calendar months with DRRA-first). All patients underwent pre-procedure ultrasound of arm arteries. All patients had RAD<2.1 mm (mean RAD 1.63 ± 0.27 mm; RAD≤1.6 mm in 73.5%). Baseline characteristics were similar between groups. Primary end-point of puncture success was significantly lower in DRRA vs RRA group [79.5% vs 98.5%, p < 0.0001]. Puncture success was also lower in the subgroup of patients with RAD <1.6 mm Vs. ≥ 1.6 mm in the DRRA group ( p < 0.0001). The secondary end-point of puncture time was significantly higher (2.1 ± 1.4 min vs. 1.0 ± 0.45 min, p < 0.00001) in the DRRA Vs. RRA group. The occurrence of vascular access site complications (including access site hematomas), radial artery occlusion (RAO) and distal RAO at day 1 and day 30 were similar between RRA and DRRA groups.Non-vascular access-site complication was seen only in the DRRA group. Conclusion DRRA is a safe and effective access for coronary procedures; though technically challenging in patients with SDRA (RAD<2.1 mm; mean RAD 1.63 ± 0.27 mm), with lower puncture success and higher puncture time compared to RRA.

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Osteomyelitis is commonly caused by Staphylococci, Streptococci, Escherichia coli, and anaerobes. There have been cases of rare organisms like Klebsiella pneumoniae (Kp) being initially overlooked as causes of osteomyelitis. We report a case of an elderly cirrhotic adult male transferred for further management of liver failure, who was subsequently diagnosed with Kp osteomyelitis and sepsis. He had a history of blunt leg trauma, and MRI of the leg revealed osteomyelitis, with a negative workup for other sources of infection. Kp osteomyelitis is reported in less than 100 cases, mainly in pediatric and sickle-cell patients. There are no pathognomonic imaging findings. Lesions may be metastatic, with rapid widespread destruction and exuberant periosteal reaction. Kp is a rare, under recognized cause of osteomyelitis in immune-suppressed adults. Given its pathogenicity, early identification is critical.

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