Short-Term Survival Benefit of Radial PCI Increases with Baseline Bleeding Risk

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Percutaneous coronary intervention (PCI) performed via radial access is associated with lower short-term mortality, according to a registry study published in the October 14, 2014, issue of the Journal of the American College of Cardiology. The higher patients’ baseline bleeding risk, the more they benefit—but paradoxically, such patients are less likely to be treated radially.

Researchers led by Mamas A. Mamas, DPhil, BM, BCh, of the University of Manchester (Manchester, England), looked at 348,689 transradial (43.4%) and transfemoral (56.6%) PCI procedures documented in the British Cardiovascular Intervention Society (BCIS) database—representing 80% of all PCI procedures performed in the United Kingdom between 2006 and 2011. Patients were stratified by baseline risk based on a modified Mehran risk score, with each unit increase corresponding with a 10% additional risk of in-hospital major bleeding (P < .0001):
  • Low: < 10
  • Moderate: 10-14
  • High: 15-19
  • Very high: ≥ 20
 Patients undergoing transfemoral PCI were older and more likely to have diabetes, have cardiogenic shock, or require an intra-aortic balloon pump. Patients treated radially were more likely to present with an ACS and be treated with GPIs and DES.

Increased baseline bleeding risk was associated with greater risk of 30-day mortality (OR 1.18 per baseline bleeding risk unit; 95% CI 1.17-1.18; P < .0001). Multivariable analysis confirmed that the strongest independent predictor of 30-day mortality was bleeding risk, with the magnitude of the association increasing with the degree of risk (table 1).

Table 1. Multivariable Analysis: Impact of Baseline Bleeding Risk on 30-Day Mortalitya



95% CI







Very High



a P < .001 for all.

Other independent predictors included diabetes (OR 1.37; 95% CI 1.21–1.54) and transradial access (OR 0.82; 95% CI 0.73–0.91; P < .0001 for both).

Mortality at 30 days was lower with transradial (0.91%) vs transfemoral (1.74%) access, and multivariate analysis demonstrated that the radial approach was independently associated with a reduction in this outcome (OR 0.65; 95% CI 0.59-0.72; P < .0001). Moreover, the survival benefit increased with the rise in baseline bleeding risk. For example, radial PCI was associated with a 27% risk reduction in patients in the lowest risk group and a 47% risk reduction in the highest risk group.

“This suggests that the greatest benefit of [transradial access] was recorded in those at highest risk of bleeding complications,” Dr. Mamas and colleagues observe. Nonetheless, transradial access was “paradoxically” used less in those at highest (40.1%) vs lowest (43.2%) bleeding risk (P < .0001), they write.

Finally, analysis of 102,664 propensity-matched patient pairs confirmed that mortality increases with increased baseline bleeding risk.

‘Radial Treatment Paradox’ Understandable—But Not Acceptable

The authors offer possible explanations for the absence of a relationship between baseline bleeding risk and choice of access site. “Many of the bleeding risk stratification scores have been published recently and therefore could not have been used before 2010,” they write. These scores also often require test results, which may not be available at the time of presentation in patients at highest risk for bleeding. Finally, procedure-related factors can have an impact on access site choice in high-risk patients.

Still, they assert, the dataset is comprehensive and reflects “real-world experience.”

In an editorial accompanying the article, Olivier F. Bertrand, MD, PhD, of the Quebec Heart and Lung Institute (Quebec City, Canada), and Sunil V. Rao, MD, of the Duke Clinical Research Institute (Durham, North Carolina), say the “radial treatment paradox … has previously been observed in the NCDR data, albeit with a much narrower gap than in the BCIS database, presumably due to the greater popularity of the radial approach in the United Kingdom.”

They add that the paradox is not surprising considering that female sex and older age—variables known to be associated with higher bleeding risk—have also been linked with a higher radial failure rate, especially in new operators.

“These data, along with other studies delineating the risk-treatment paradox related to bleeding avoidance strategies, strongly support identifying a patient’s bleeding risk preprocedurally and consciously implementing radial approaches in the patients whenever possible,” they comment. Now is the time for radial access to become the “default site” for both diagnostic coronary angiography and PCI, the editorial authors conclude.


1. Mamas MA, Anderson SG, Carr M, et al. Baseline bleeding risk and arterial access site practice in relation to procedural outcomes after percutaneous coronary intervention. J Am Coll Cardiol. 2014;64:1554-1564.

2. Bertrand OF, Rao SV. Baseline bleeding risk and benefit of transradial PCI: making lemonade out of lemons [editorial]. J Am Coll Cardiol. 2014;64:1565-1567.

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  • Drs. Mamas and Bertrand report no relevant conflicts of interest.
  • Dr. Rao reports serving as a consultant to Terumo Medical.

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