Advances in medicine have enabled clinicians to use the radial and even ulnar arteries as alternative vascular access sites for PCI. Small studies have shown that transradial PCI is associated with lower rates of bleeding and vascular complications when compared with the femoral approach. Moreover, randomized trial data have demonstrated that both radial and femoral approaches are equally effective and safe in patients with acute coronary syndrome (ACS).
“Despite the growing body of evidence supporting greater use of transradial approach to PCI, only 1.32% of PCIs from 2004 to 2007 in the United States were transradial,” says Dmitriy N. Feldman, MD, FACC, FSCAI. “One of the potential reasons for its less frequent use is the lack of operator experience, but multiple training programs have been implemented throughout the U.S. since 2007 to address this issue. The impact of these efforts, however, has not been evaluated.”
Assessing More Recent Data
In Circulation, Dr. Feldman and colleagues had a retrospective cohort study published that looked at 6 years of data from more than 2.8 million procedures in the CathPCI Registry. According to their results, radial access accounted for 6.3% of PCI procedures from 2007 to 2012. Importantly, transradial PCI was associated with a lower risk of bleeding (adjusted odds ratio [OR], 0.51) and vascular complications (adjusted OR, 0.39) when compared with transfemoral PCI. The reductions seen in bleeding and vascular complications were consistent across important subgroups of age, sex, and clinical presentation.
“Since earlier reports have been released, there has been a 13-fold increase over a 6-year period in the use of transradial PCI,” says Dr. Feldman. “These findings are encouraging, especially since this approach appears to have similar efficacy and improved safety when compared with transfemoral PCI. Unfortunately, there still appears to be inter-hospital and geographic variation in its adoption. Transradial PCI also remains underused in people at high risk for bleeding, such as older patients, women, and those presenting with ACS.”
Fostering Greater Adoption
The findings from Dr. Feldman and colleagues may serve as an opportunity to improve overall PCI safety by increasing the application of radial access to higher-risk patients. “Our analysis adds to the growing body of evidence from previous reports and studies showing an accentuated benefit of transradial PCI in terms of absolute risk reduction of vascular and bleeding complications,” Dr. Feldman says. “The key is to get more clinicians adequately trained in performing transradial PCI. Greater adoption of transradial PCI will occur as operators make efforts to overcome the learning curve associated with the technique. Wider adoption of radial PCI in interventional practice, particularly in high-risk patients with STEMI, may ultimately improve overall PCI safety and possibly lead to better survival rates.”
Readings & Resources (click to view)
Feldman DN, Swaminathan RV, Kaltenbach LA, et al. Adoption of radial access and comparison of outcomes to femoral access in percutaneous coronary intervention: an updated report from the National Cardiovascular Data Registry (2007-2012). Circulation. 2013;127:2295-2306. Available at: http://circ.ahajournals.org/content/127/23/2295.full.
Doyle BJ, Rihal CS, Gastineau DA, Holmes DR Jr. Bleeding, blood transfusion, and increased mortality after percutaneous coronary intervention: implications for contemporary practice. J Am Coll Cardiol. 2009;53:2019-2027.
Rao SV, Ou FS, Wang TY, Roe MT, Brindis R, Rumsfeld JS, Peterson ED. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2008;1:379-386.
Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J. 2009;157:132-140.
Bertrand OF, Larose E, Rodés-Cabau J, et al. Incidence, predictors, and clinical impact of bleeding after transradial coronary stenting and maximal antiplatelet therapy. Am Heart J. 2009;157:164-169.