Registry Study: Transradial Appears to Best Transfemoral PCI Regardless of Presentation

Use of transradial access for PCI reduces not only bleeding and access site complications but also 30-day mortality compared with a transfemoral approach, according to an observational study published in the January 2015 issue of JACC: Cardiovascular Interventions. Moreover, the radial advantage exists regardless of whether vascular closure devices are used after transfemoral access or if patients are stable or unstable.

The findings suggest that “the benefits of the transradial approach seen in selected populations in randomized trials and other observational studies may translate into real patient benefits in day-to-day clinical practice,” the study authors say.Take Home: Registry Study: Transradial Appears to Best Transfemoral PCI Regardless of Presentation

James Nolan, MD, of University Hospital of North Staffordshire (Stoke-on-Trent, England) and colleagues leveraged the British Cardiovascular Intervention Society (BCIS) PCI database to evaluate the outcomes of 495,913 procedures performed between 2007 and 2012 in relation to access site. A transradial route was used in 45% of cases and a transfemoral in 49.6%; closure devices were used in 60% of the transfemoral cases. Patients were classified by indication for PCI as stable, NSTE-ACS, or STEMI.

Compared with transfemoral patients, transradial patients were younger and more often male. They also were less likely to previously have had an MI or undergone CABG. The transradial route was used more frequently for ACS but less often in patients with preprocedural shock or ventilation. In addition, the use of GPIs, bivalirudin, and thrombus aspiration devices was more common in transradial patients, whereas that of circulatory support was less frequent.

Radial Access Superior Across the Board

On multivariate analysis, transradial PCI was associated with reduced odds of 30-day mortality, bleeding, and access site complications for all presentations evaluated. The likelihood of MACE (in-hospital mortality, MI, or repeat intervention) was lower only among patients with unstable syndromes (table 1).

 Table 1. Multivariate Analysis of Outcomes by Presentation

Analysis of a propensity-matched cohort (76,469 pairs) confirmed that all of the above outcomes were improved with radial access compared with femoral access using a vascular closure device (each P < .001).

Improvements Seen Despite Learning Curve

In an email with TCTMD, Dr. Nolan commented that the BCIS database enabled researchers “to study the impact of radial access on outcomes in a very large cohort of patients undergoing PCI, with the data collected at a time when national practice evolved from predominantly transfemoral to predominantly transradial access [and] many UK operators were early in their transradial learning curve.”

Judging by the study results, he said, “in the UK, large-scale rapid evolution of national access site practice occurred with no evidence for adverse learning curve effects.”

Sunil V. Rao, MD, of Duke University Medical Center (Durham, NC), told TCTMD in an email that the current “study [is] one of several that have clearly shown an advantage of radial access. This advantage appears to be manifest across all patient groups. The idea of selecting patients for a radial approach means not only that operators won’t [have as much of a chance to] overcome the radial learning curve but also that they may be denying the benefits of the radial approach to a significant proportion of their patients.”

Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), cautioned that there are always risks in drawing firm conclusions from observational studies. But in a telephone interview with TCTMD, he added, “There are definitely emerging data [showing] that access site complications can be reduced with [radial access]…. Particularly in high-risk patients, radial access does seem to make a lot of sense.”

A Tipping Point in the United States?

The observation that the prevalence of transradial PCI is increasing even in the United Kingdom, where the rate of its adoption is higher than in the United States, confirms an overall trend, he noted.

There will always be “certain cases and anatomic scenarios… for which it makes clinical sense to do the cases femorally,” Dr. Kirtane acknowledged. “And fundamentally, irrespective of the access site, the quality of the angiography and the PCI must be good. That’s the prerequisite for good clinical care.”

Emerging research, especially with respect to bleeding avoidance strategies during transfemoral access, makes this an ongoing conversation, he added. “But we know that radial adoption is on the rise here in the US and seems to have already hit the tipping point. I think that’s a good thing for patients and clinicians alike.”

 


Source:
Ratib K, Mamas MA, Anderson SG, et al. Access site practice and procedural outcomes in relation to clinical presentation in 439,947 patients undergoing percutaneous coronary intervention in the United Kingdom. J Am Coll Cardiol Intv. 2015;8:20-29.

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Registry Study: Transradial Appears to Best Transfemoral PCI Regardless of Presentation

Disclosures
  • Dr. Nolan reports no relevant conflicts of interest.
  • Dr. Rao reports serving as a consultant for Terumo Medical.
  • Dr. Kirtane reports institutional research grants from Abbott Vascular, Abiomed, Boston Scientific, Eli Lilly, Medtronic, St. Jude Medical, and Vascular Dynamics.

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