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Transradial access for percutaneous coronary intervention (PCI), though still rare, is rapidly becoming more common at Veterans Affairs (VA) hospitals, according to study published online August 13, 2013, ahead of print in Circulation: Cardiovascular Interventions. At centers doing at least 50 transradial cases per year, the technique is associated with a lower risk of post-PCI blood transfusion.

Investigators led by Antonio Gutierrez, MD, of Brigham and Women’s Hospital (Boston, MA), analyzed data from the Clinical Assessment, Reporting, and Tracking (CART) program on 21,485 patients treated at the 49 out of 60 VA facilities that performed at least 1 radial PCI procedure in the study period between October 2007 and September 2010.

Cases were divided by whether they occurred at sites performing a high volume of at least 50 radial PCIs per year (n = 2,414 procedures at 5 sites) or a lower volume of radial PCIs (n = 19,044 procedures at 44 sites).

No Survival Benefit Seen

Overall, 1,309 radial procedures were performed (6.1%). Volume varied widely among VA hospitals, with 20% of sites performing only 1 to 3 cases during the study period and 4% employing radial for 40% of their cases. There was a fourfold increase in the use of radial PCI over the course of the study, from 2.1% in 2007 to 8.8% in 2010.

On propensity-matched analysis (n = 5,060 cases), radial PCI was associated with reduced rates of blood transfusion at high-volume sites compared with femoral PCI, though mortality was unaffected (table 1).

Table 1. Outcomes by Access Route at High-Volume Sites

At low-volume sites, however, rates of blood transfusion at 3 and 7 days did not differ by access route. At 3 days, 1.1% of patients undergoing femoral PCI required a transfusion, compared with 1.4% of radial PCI patients (P = 0.615); at 7 days, those rates were 1.7% and 1.6%, respectively (P = 0.926). Mortality again was similar between the 2 groups.

Further analysis of transfusion rates showed that the probability of being transfusion-free was higher for radial vs. femoral patients who underwent the procedure at high-volume sites (P = 0.02) but not at low-volume sites.

Radial Becoming Routine?

The authors conclude that increasing use of radial PCI could be beneficial. “These data suggest that routine use of [radial] PCI and wider application of radial PCI, both of which would likely to greater technical proficiency with the procedure, have the potential to improve safety outcomes among veterans undergoing PCI,” they write.

Transfusions were administratively reported rather than clinically reported, meaning that other clinical bleeding events could have been overlooked. Adding in those additional events, however, would likely “increase the robustness of our results because using blood transfusion as a surrogate marker for bleeding underestimates the occurrence of this event,” Dr. Gutierrez and colleagues note.

Ian Gilchrist, MD, of Hershey Medical Center (Hershey, PA), told TCTMD in an e-mail communication that while transradial PCI is in a “growth phase” in the United States, further uptake will require more than increasing evidence of improved outcomes.

“I don’t think the ‘holdouts’ for transradial will switch just [due to] data,” he said, adding that lower volume providers will only change when more patients request the procedure or threaten to leave a practice.

Dr. Gilchrist reported being unsurprised that the new study did not pick up on any difference in mortality, since the patients were relatively stable and thus had a low risk of death. STEMI/NSTEMI patients, who tend to be higher risk, made up only about 20% of the total population, he noted.

Still, VA studies have the potential to make substantial changes to patient care, he concluded. “Analysis and publication of this type of data will be helpful in driving more to ‘best practices’ that save patients either blood, time in the hospital, or maybe even lives in the long run,” Dr. Gilchrist said.

 

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Source:
Gutierrez A, Tsai TT, Stanislawski MA, et al. Adoption of transradial percutaneous coronary intervention and outcomes according to center radial volume in the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) program. Circ Cardiovasc Interv. 2013;Epub ahead of print.

 

 

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