Small Study Supports Safety of Radial PCI in STEMI Patients

Download this article's Factoid in PDF (& PPT for Gold Subscribers)

A small, observational study lends additional support for the safety and feasibility of primary percutaneous coronary intervention (PCI) via a transradial approach. The study, published online July 30, 2012, ahead of print in the American Journal of Cardiology, showed trends toward fewer vascular complications and shorter length of hospital stay with transradial vs. transfemoral access.

Saibal Kar, MD, of Cedars-Sinai Medical Center (Los Angeles, CA), and colleagues evaluated 150 consecutive STEMI patients who underwent primary PCI by femoral (n = 104) or radial (n = 46) access at their institution over a 24-month period. The operators performing transfemoral procedures (n = 7) had at least 10 years experience with PCI, while the single operator using transradial access had comparable femoral experience but no experience with transradial PCI for STEMI.

Among the transradial interventions, 40 (83%) were performed from the left approach, and 8 (17%) from the right approach. Five transradial procedures (10%) were crossed over to femoral access due to tortuous anatomy or suboptimal guiding catheter support. All crossovers occurred in the first year of the study.

The transradial and transfemoral groups were comparable with respect to hospital door-to-balloon time (79.2 ± 32.3 minutes vs. 86.8 ± 51.8 minutes; P = 0.67) and amount of contrast agent used (190.5 ± 101.5 mL vs. 172.2 ± 81.7 mL; P = 0.24).

However, cath lab door-to-balloon time and total fluoroscopy time were longer in the transradial group compared with the transfemoral group. Postprocedural TIMI grade 3 flow and rates of vascular complications (with none in the radial group) and in-hospital death were similar (table 1).

Table 1. Procedural Characteristics and Outcomes

There was a trend toward a shorter duration of hospital stay in the transradial access group compared with the transfemoral access group (5.1 ± 7.5 vs. 5.4 ± 4.8; P = 0.112).

Operator’s Skill Improved Over Time

“The primary concern of interventional cardiologists versed in [transfemoral] access is the learning curve associated with [transradial] access,” the study authors write. “We have shown that even for an inexperienced [radial] operator, the door-to-balloon and catheterization laboratory door-to-balloon times were acceptable at the outset and improved significantly over the course of the study.”

Previous studies have shown crossover rates from transradial to transfemoral access of approximately 2%, but the authors say their crossover rate of 10% “is likely a reflection of the initial inexperience of the [transradial] access operator, as there were no crossovers during the last 12 months of the study.”

Dr. Kar and colleagues acknowledge that the study was underpowered to compare clinical outcomes.

Small but Encouraging

James Tift Mann III, MD, of Wake Heart and Vascular Associates (Raleigh, NC), told TCTMD in a telephone interview that he was surprised by the low rate of bivalirudin use (only 2 patients received it) and the relatively high rate of glycoprotein IIb/IIIa inhibitor use (15% in the transradial, 70% in the transfemoral group).

“There’s no question that transradial access is better,” Dr. Mann said. “Studies like this are encouraging because they demonstrate that operators in the [United States] are beginning to do more complex procedures using transradial access, or at least attempting to do so. Although this paper is the experience of a single operator, it’s good to see that even a beginner can get reasonable door-to-balloon times.”

Dr. Mann said while this study cannot be compared with larger multicenter randomized trials such as RIVAL and the recently published RIFLE-STEACS, what all of them have in common is that they show that “the femoral approach continues even in 2012 to have an access complication rate of about 4%. That should mean something to operators, and it’s a real problem in these STEMI patients because they are so heavily anticoagulated.”

Study Details

At baseline, there were no differences between the groups with respect to age, gender, or prevalence of diabetes.

All patients were treated with aspirin and clopidogrel (300- or 600-mg loading dose followed by 75-mg daily dose). A weight-adjusted intravenous heparin bolus (70-100 U/kg) was administered before PCI, titrated to a target activated clotting time of 250 to 350 seconds.

 

---

Source:
Ibebuogu UN, Cercek B, Makkar R, et al. Comparison between transradial and transfemoral percutaneous coronary intervention in acute ST-elevation myocardial infarction. Am J Cardiol. 2012;Epub ahead of print.

 

 

Related Stories:

• RIFLE-STEACS Published: Transradial PCI Lowers Mortality in STEMI Patients
• Patient Radiation Exposure Similar with Radial, Femoral Access
• Radial Approach Paving the Way to Better Outcomes in Acute MI Patients