Benefits of Transradial PCI May be Limited to High Volume Centers

CHICAGO, IL—Percutaneous coronary intervention (PCI) performed via transradial access may result in fewer blood transfusions and even lower mortality compared with transfemoral access, but only at higher volume centers, according to data presented March 25, 2012, at the annual American College of Cardiology/i2 Scientific Session.

Antonio Gutierrez, MD, of Duke University Medical Center (Durham, NC), and colleagues investigated rates and outcomes of transradial PCI in the Veterans Health Administration (VA) system by looking at 24,143 consecutive patients from 60 VA hospitals who received PCI from October 1, 2007, to September 30, 2010.

The vast majority received transfemoral (n = 22,834) vs. transradial (n = 1,309) PCI, but the rate of patients treated via transradial access rose over the course of the study (2.1% to 9.7%). In addition, the rate of sites performing transradial PCI rose from 2.3% to 11.4%, while the rate of sites in the highest quartile of transradial PCI experience (≥ 18 procedures) increased from 6.15% to 30.6%.

Benefits Come With Experience

In the overall cohort, there was no difference in procedural success between patients receiving transradial and transfemoral PCI (97.2% vs. 96.4%). Nor were there differences between the 2 patient groups in blood transfusions at 7 days (2.1% vs. 1.2%), or death at 30 days (1.6% vs. 1.2%) or 1 year (6.4% vs. 5.7%).

Likewise, among propensity matched sites performing transradial PCI (n = 49), the risk of blood transfusion at 3 and 7 days, and the risk of death at 30 and 360 days was no different with transradial vs. transfemoral PCI (table 1).

Table 1. Bleeding, Mortality Risk: Transradial vs. Transfemoral PCI in Propensity Matched Cohort

 

However, the top quartile of propensity matched centers performing transradial PCI showed a lower risk of transfusion with radial vs. femoral access (P = 0.03).

In the same propensity matched cohort, patients treated at centers in the top quartile of sites performing radial PCI showed a lower mortality risk with radial vs. transfemoral procedures at 3 (HR 0.6; 95% CI 0.3-0.9) and 7 days (HR 0.7; 95% CI 0.4-1.0). These results also projected out to a lower mortality risk with transradial PCI at 30 days (HR 0.6; 95% CI 0.4-0.9).

“These data suggest that greater expertise in the transradial approach may significantly improve outcomes amongst veterans undergoing PCI,” Dr. Gutierrez said, adding that, “wider adoption of transradial PCI in the VA system may [do the same].”

He noted that the VA has funded an initiative to support transradial access training to increase use of the technique in the VA health system.

Operator Info Missing

Mark Hlatky, MD, of the Stanford University School of Medicine (Stanford, CA), pointed out that a missing factor in the analysis is physician preference and experience. “I can’t help but think there’s a huge issue with who the operators are,” he said. “It seems to me you need to look into the physician component of this.”

Dr. Gutierrez agreed, noting that these data will be included in the full paper.

The study’s senior author, Sunil V. Rao, MD, also of Duke University Medical Center, addressed a question concerning slower door-to-balloon times with radial PCI for patients with STEMI.

“There is a little bit of a price to pay with respect to door to balloon times,” he acknowledged, adding, though, that a recent meta-analysis shows the difference is not overly excessive. “When you meta-analyze all the trials of radial vs. femoral in STEMI, you end up spending on average 1.76 minutes longer with radial, but you actually get a mortality benefit that’s been confirmed in other studies.”

He stressed, though, that the operators in those studies are extremely experienced.

“So the rub of this analysis and others is that in experienced hands, the radial approach does in fact appear to be associated with better outcomes across the spectrum of disease,” Dr. Rao said.

Study Details

Patients who received transradial PCI had more comorbidities than those receiving transfemoral PCI, with higher rates of diabetes, dyslipidemia, hypertension, tobacco use, CVD, peripheral disease, and COPD. They had lower rates, though, of ACS, with higher fluoroscopy time (22 min vs. 19 min; P < 0.001) and similar rates of multivessel disease.

 

 

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Source:
Gutierrez A. Prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention.  Insights from the National VA Clinical Assessment, Reporting and Tracking Program. Presented at: American College of Cardiology Scientific Session; March 25, 2012; Chicago, IL.

 

Disclosures:

• Dr. Gutierrez reports no relevant conflicts of interest.

 

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