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ESC: Use Radial Access First for PCI
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Three European associations, including the European Association of Percutaneous Cardiovascular Interventions and the Working Group on Thrombosis of the European Society of Cardiology, have issued a consensus document today that advocates for a radial-first approach for PCI.
The paper, which was published today in EuroIntervention and includes input from the Acute Cardiovascular Care Association, provides an evidence-based view on the technical, clinical and organizational implications of using the radial access for coronary angiography and interventions, including advantages, disadvantages and expertise requirements.
The authors cite meta-analyses of randomized studies, including the RIVAL and RIFLE trials, which show a reduction in access site-related major bleeding for radial vs. femoral access. In addition, they mention one meta-analysis and several observational studies that suggest a reduction in vascular access-site complications and site-related major bleeds with radial access might improve patient outcomes.
However, since there is a small percentage of patients in whom the radial approach does not work, the consensus document also emphasizes the importance of maintaining expertise in the femoral approach. “All radial-proficient teams should aim to maintain optimal proficiency in femoral procedures as well. Some low-risk patients for femoral access site complications and procedures requiring femoral access ([intra-aortic balloon pump], radial access failure or if guiding catheters ≥8F are required) should provide a volume of cases to maintain adequate training in femoral artery puncture,” the researchers wrote.
In an accompanying press release, Ferdinand Kiemeneij, MD, inventor of radial access for PCI and a co-author of the document, said although this technique was initiated 20 years ago, there is still a lot going on to get everyone performing this procedure.
“It is taking off quite rapidly now and … this paper really adds to a more general acceptance of the technique,” said Kiemeneij, who is with the department of interventional cardiology at Onze Lieve Vrouwe Gasthuis in Amsterdam, the Netherlands. “I’m convinced that it will improve patient care overall by providing more knowledge, more training and better awareness.”
Disclosure: Kiemeneij receives Kimny catheter sales royalties from Boston Scientific. All other researchers report no relevant financial disclosures.
Perspective
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Sunil V. Rao, MD
The European clinical community wanted to put out a statement because the radial approach originated there and most of the European countries are ahead of the United States with respect to radial adoption. This is a very measured document and the authors were very reasonable in terms of their conclusion. The danger you run into when you have a number of radial enthusiasts writing a paper like this is for them to write, “The case is closed”; however, that is not what the authors have written. They have made some very good recommendations for further research. We should feel comfortable saying radial should be the default approach for patients undergoing PCI, with an asterisk, and that asterisk is you have to become proficient in the approach, particularly in situations where the clinical outcomes can really be impacted, like STEMI. The reason is because there is a door-to-balloon time clock that you have to account for and if you are not proficient with the radial approach, the patient’s myocardium is at risk. So, I agree with the authors that there is room for more investigation, not only into different patient subsets, but also in some technical aspects of the radial approach to determine what are the best strategies to reduce radiation exposure and if there are additional things we can do to reduce radial artery occlusion. The paper itself is an incredibly important contribution not only because of its scope, but because it takes the time to point areas needing more study.
Another of the important aspects of this paper is the step-wise approach that they propose for how operators can get proficient in the radial approach. For the United States in particular, there are still a lot of opportunities to train people. Right now it looks like the rate of radial procedures in the United States is around 10 to 13%, which is a great advancement over the last few years, but it is still the minority of procedures. We still have a large contingent of interventional cardiologists who need training opportunities to learn radial access.
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