Fewer Adverse Events with Radial vs. Femoral PCI in High-Risk IABP Patients

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In high risk patients receiving percutaneous coronary intervention (PCI) and intra-aortic balloon pump (IABP) support, transradial access is associated with fewer adverse events than transfemoral. The findings, according to the study appearing online October 14, 2013, ahead of print in the American Heart Journal, are related to reduced access site bleeding with transradial PCI.

For the RADIAL PUMP UP (radial versus femoral approach in PCI with IABP support) registry, researchers led by Enrico Romagnoli, MD, PhD, of Policlinico Casilino Cardiology (Rome, Italy), looked at data from 321 consecutive patients receiving IABP support during transfemoral (n = 209) or transradial (n = 112) PCI at 4 high-volume Italian centers that used the radial approach in over 70% of all cases.

Shock, ACS Common in Cases Using IABP

Cardiogenic shock or unexpected intraprocedural hypotension in the context of ACS diagnosis (93%) or acute heart failure (2%) were the common indications for IABP support, whereas it was used to prevent hemodynamic instability during high-risk PCI only in a minority of cases (5%).

The primary outcome of net adverse clinical events (NACE; cardiac death, MI, TLR, stroke, and non-CABG-related bleeding) was lower with radial access at 30 days, as were MACCE, cardiac death, and bleeding, in particular access site bleeding. Non-access site bleeding was unaffected by access route (table 1).

Table 1. Thirty-Day Outcomes

Transfemoral and transradial patients had similar baseline characteristics and cardiac risk profiles, but transfemoral patients presented with more severe hemodynamic impairment, indicated by lower systolic blood pressure (median 88 vs. 90 mm Hg; P = 0.006) and more frequent need for inotropic support (68% vs. 58%; P = 0.077) and/or mechanical ventilation (37% vs. 27%; P = 0.068). Still, both groups showed comparable preprocedural risk as assessed by EuroSCORE. TLR, stroke, and MI were also similar between the 2 groups at 30 days.

Less Bleeding Equals Fewer Transfusions

Because of the reduction in bleeding with the transradial group, particularly access site bleeding, transradial patients showed a reduction in need for blood transfusion (14.8% vs. 6.3%; P = 0.023). On multivariable analysis, transradial access was confirmed as an independent predictor of reduced 30-day NACE (HR 0.57; 95% CI 0.4-0.9; P = 0.007), while inotropic support was associated with increased NACE (HR 1.67; 95% CI 1.1-2.5; P = 0.018).

Notably, patients without bleeding showed comparable outcomes regardless of the arterial approach used.

“In this observational registry,” Dr. Romagnoli and colleagues write, “high-risk patients undergoing PCI and requiring IABP support appeared to have fewer NACE if transradial access was used instead of transfemoral, mainly due to fewer access-related bleedings.” The authors call for further controlled studies to confirm or refute these findings.

According to R. Lee Jobe, MD, of North Carolina Heart and Vascular (Raleigh, NC), a well-known advantage of transradial access is reduced bleeding and vascular complications. “And anything we can do that reduces the need for transfusion, that reduces the chance for vascular complications, is only going to improve mortality,” he told TCTMD in a telephone interview.

He added that the findings may help explain why patients with cardiogenic shock and IABP support—who typically receive transfemoral PCI in the United States—do so poorly, “because now this study demonstrates the superiority of transradial access for these patients. By removing a large amount of the vascular complications that occur, there is a benefit shown.”

‘Consider Radial First, Not as a Bailout’

Dr. Jobe observed that while a drawback of the study is its retrospective, observational nature, a randomized trial in this venue may prove problematic. “It would be difficult to consent and randomize a patient who’s in cardiogenic shock at the time that it happens, and it may be that observational data, both retrospective and prospective, may be the best chance we have to look at things like this,” he said.

Nevertheless, existing studies still support transradial PCI for the sickest patients, Dr. Jobe insisted. “I think this continues to support the notion that for STEMI and cardiogenic shock patients, the radial approach should be considered the default approach unless there’s a reason not to use it,” he said. “The change in paradigm needs to be that for [such patients], we need to consider radial first, not as a bailout.”

For such a paradigm shift to occur, he added, “the key is that you have to become an experienced operator to be comfortable with radial access.”

 

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Source:
Romagnoli E, Vita MD, Burzotta F, et al. Radial versus femoral approach comparison in percutaneous coronary intervention with intraaortic balloon pump support: The RADIAL PUMP UP Registry. Am Heart J. 2013;Epub ahead of print.

 

 

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