Radial Approach Paving the Way to Better Outcomes in Acute MI Patients

PARIS, France—Results from 2 observational studies presented May 15 at EuroPCR are consistent with a growing body of literature demonstrating improved outcomes after transradial percutaneous coronary intervention (PCI) for acute myocardial infarction (MI).

Scottish Registry

Miles W.H. Behan, DM, MRCP, of Edinburgh Heart Centre (Edinburgh, United Kingdom), described his group’s efforts at tracking all primary (n = 2,241) and rescue (n = 2,293) PCI procedures performed in Scotland from April 2000 to March 2009, as captured in the prospective Scottish Coronary Revascularization Register. Procedures were stratified according to those performed via the transfemoral (47.2%; n = 2,142) or transradial (52.8%; n = 2,392) route. Over the course of the study, the prevalence of transradial PCI for emergency cases grew from none in 2000 to 80.5% in 2009 (P < 0.001).

Patients receiving transradial PCI were more likely to be male and have multiple comorbidities, hypertension, and LV dysfunction, but less likely to have renal impairment, multivessel disease, or cardiogenic shock.

Procedural success was higher with transradial PCI (97.1% vs. 93.9%; P < 0.001), while procedural complications were lower with radial access, including vascular access complications (0.3% vs. 1.8%; P < 0.001) and major bleeding (0.1% vs. 1.3%; P < 0.001).

At 1 year, hard outcomes were improved with transradial PCI including MI (11.1% vs. 16.7%; P < 0.001), stroke (0.6% vs. 1.0%; P = 0.002), and death (8.0% vs. 15.1%; P < 0.001). On multivariable analysis, transradial PCI remained an independent predictor for reductions in each of these outcomes compared with transfemoral PCI (table 1).

Table 1. Multivariable Analysis: Transradial vs. Transfemoral Emergency PCI

When divided into primary vs. rescue PCI, transradial access no longer independently predicted improved outcomes with regard to procedural success or stroke in either primary PCI or rescue PCI, though strong trends were shown favoring radial access in each case.

There was a definite learning curve that took place over the course of the study. Procedural success rose from 90.8% in 2000 to 97.7% in 2009 (P < 0.007), while a steady drop occurred in transradial complication rates (13.0% to 5.9%; P < 0.003).

Dr. Behan noted that radial access is now the preferred route for the majority of  PCI cases—whether primary or rescue—performed in Scotland.

A Clear Message: It’s the Way to Go

“Radial access appears to be associated with improved earlier and longer term clinical outcomes after adjustment for baseline characteristics,” he said. “Radial access should be actively encouraged in this high-risk group.”

Session co-chair Milan Chag, MD, of the Heart Care Clinic (Ahmedabad, India), commented that “it’s a very clear message that not just [procedural rates] but even clinical outcomes are better with the radial approach in a very high-risk group of primary and rescue PCI patients. More and more it’s becoming [clear] that radial is the way to go.”

Co-chair Farrel Hellig, MD, of Sunninghill Hospital (Johannesburg, South Africa), observed that primary PCI seems to be the ideal setting for radial access. “We have learned that door-to-balloon times are not compromised and procedural success is high, and we know that radial access generally reduces bleeding complications, so this is the best setting for the radial approach of all clinical settings,” he said.

Dr. Behan, meanwhile, offered a tip from his own experience. “If you are the only radial operator when you come into a cath lab, it never goes very well,” he said. “You need the whole team behind you and the lab to be set up [for radial]. Then it’s a very smooth [process] and you get very good results. But if the center favors femoral and you’re the only radial operator, it won’t be good unless there’s a big push for radial.”

Spanish Single-Center Study

Francisco De Asis Diaz-Cortegana, MD, of Hospital Universitario Infanta Cristina (Badajoz, Spain), presented results from 641 STEMI patients at his institution treated via either transfemoral (n = 332) or transradial (n = 309) PCI. Access site crossover was below 2% in each group. Procedural characteristics such as overall time, fluoroscopy time, and contrast volume were similar between the 2 groups. Procedural success, meanwhile, was higher with transradial PCI (96.1% vs. 88.6%; P < 0.001), as were deferments of PCI for significant noninfarct-related lesions (11.0% vs. 2.7%; P = 0.01). This, however, did not alter shorter length of hospital stay that occurred with transradial patients.

In-hospital complications were lower with transradial PCI, including death, major bleeding, and vascular access site issues (table 2).

Table 2. In-hospital Complications

“Use of the transradial approach for emergency PCI in patients with STEMI was associated with fewer in-hospital complications and a shorter length of hospital stay than the femoral approach, with a similar success rate as the transfemoral approach,” Dr. Diaz-Cortegana said. “So the radial approach could become the preferred approach in this setting.”

Dr. Hellig noted a recurring theme, “one of high success rates [and] low complication rates with radial access.”

After both radial presentations, he asked the audience, “Do we have consensus now that radial access is the preferred access route for acute myocardial infarction?” to which almost all attendees raised their hands. “You’ve done a convincing job,” Dr. Hellig commented to the presenters.

Sources:

1. Behan MWH. Comparison of outcomes following radial versus femoral approaches in primary and rescue PCI: Analysis of the Scottish national database. Presented at: EuroPCR; May 15, 2012; Paris, France. 
2. Diaz-Cortegana FDA. Safety and efficiency of the radial approach for emergency angioplasty in ST-segment elevation acute myocardial infarction (STEMI). Presented at: EuroPCR; May 15, 2012; Paris, France. 

Disclosures:

·        Drs. Behan and Diaz-Cortegana report no relevant conflicts of interest.

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