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A patient guide explaining the risks and benefits of femoral and radial artery access in coronary angiography leads to improved decision making and more knowledgeable patients. But the strategy does not appear to change clinical variables or outcomes, according to a single-center nonrandomized trial from Canada published online April 10, 2012, ahead of print in Circulation: Cardiovascular Quality and Outcomes.

Another study, the randomized RIVAL (RadIal Vs. femorAL) trial, recently showed in over 7,000 ACS patients that the 2 access routes yield similar overall safety and effectiveness in coronary angiography, though the radial approach does result in fewer vascular complications in high-volume centers. The current results, therefore, speak to the ongoing debate that places the decision of radial vs. femoral in a “gray zone,” where patient preference can play a role.

Better-Informed patients

Jon-David R. Schwalm, MD, of McMaster University-Hamilton Health Sciences (Hamilton, Canada), and colleagues tested a decision aid in 150 patients at their center who were deemed eligible for either radial or femoral access. Patients were randomized to usual care (n = 74) or a strategy that involved them in the decision-making process (n = 76). The latter group was first given a 3-page booklet 30 to 60 minutes before angiography that explained both access options and provided the known risks and benefits of each. After receiving the guide, patients could then state their preferred route.

More patients in the decision-aid group had a history of stroke or TIA, but the groups were otherwise similar at baseline.

The effect of the patient guide was measured on a validated 16-item scale that evaluates personal perceptions of uncertainty in decisions, factors contributing to that uncertainty, and effectiveness of decision making. Patients given the guide had less conflict over their decisions than did controls—resulting in a lower mean total conflict score—and were more likely to make their own choice for radial or femoral access (table 1).

Table 1. Influence on Decision Making

^a Primary endpoint; scores range from 0 to 100, from no to highest possible conflict.

Though the guide resulted in more patients than physicians being the decision makers, the actual choice did not differ. Approximately three-quarters of patients chose radial access, including 73.7% of the decision-aid group and 78.8% of the control group (P = 0.50). There also was no difference in the vascular access route that was eventually received, with 68.4% and 75.7% (P = 0.32) undergoing radial access with and without the guide, respectively, or in the success of vascular access (94.7% vs. 97.3%; P = 0.68).

More patients in the intervention group had better-informed value congruence with the access site compared with the control group—in other words, more patients given the guide knew what they wanted and subsequently received what they wanted.

Patients given the decision aid also had more knowledge about their treatment. They were more likely to correctly answer questions regarding the chances of success, the shortest procedure time, and which option is considered more technically challenging.

High Volume Centers Only?

Although this study was not powered to illuminate any difference in clinical outcomes with the patient guide, Dr. Schwalm explained that reducing decisional conflict on its own is a welcome result. “You can allow your patients to be involved in this decision,” he said in a telephone interview with TCTMD. “It isn’t a slam-dunk decision . . . with respect to adverse events with one access versus another.”

And despite the similar rates of radial vs. femoral access in the study, more patients did receive radial access (72%) than would normally in this particular tertiary care center’s usual practice pattern (41.6%). Dr. Schwalm said that since the study’s completion, the center’s rate of radial access has markedly increased.

Notably, though, a strategy involving such a guide would only be relevant in high-volume centers where operators can offer both radial and femoral access. This stipulation might be difficult to meet in the United States, where radial access is not used as often as in Canada.

According to Philippe Généreux, MD, of Columbia University Medical Center (New York, NY), each center should assess its own statistics and ability to deliver safe and effective femoral and radial access before offering the guide to patients.

“That being said, the results of this trial should probably be an incentive for the low-volume radial center to say, ‘Well, the patient prefers radial, so maybe we should learn it and be properly trained to meet the expectations,’” he told TCTMD in a telephone interview.

Both physicians agreed that there is an ongoing movement toward radial access, and results like this may hasten such a shift.

However, even where both access routes can be safely offered in a candidate for either option, there is still some discussion among the cardiology community as to which is preferred, Dr. Généreux pointed out. “I think informing the patient is great, but in specific situations the cardiologist needs to make the best decision for the patient,” he said, adding, “You cannot ask the patient to be a doctor in 30 minutes.”

Related Stories:

• Radial vs. Femoral Angioplasty: Still RIVALs
• Benefits of Transradial PCI May be Limited to High Volume Centers
• Transradial Primary PCI Lowers Mortality in STEMI Patients

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