‘Radial first’ strategy brings benefits to complex, high-risk PCI procedures
Key takeaways:
- Registry data show transradial access was used for most patients who underwent complex, high-risk PCI.
- Transfemoral access was independently associated with higher odds for mortality and other adverse outcomes.
Transradial access is now the predominant access site for complex, high-risk PCI procedures and is associated with significantly lower risk for mortality, major bleeding and other adverse events compared with transfemoral access, data show.
Countries have increasingly adopted transradial access for PCI due to data demonstrating bleeding and mortality benefits compared with transfemoral access, as well as factors such as patient preference, comfort and reduced health care costs, Mamas A. Mamas, DPhil, MRCP, professor of cardiology in the Keele Cardiovascular Research Group at Keele University in Staffordshire, U.K., and colleagues wrote in Catheterization and Cardiovascular Interventions.
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European and North American guidelines now endorse a “radial first” strategy, which has paved the way for considering transradial access for more complex, high‐risk PCI procedures, the researchers wrote.
“In recent years, much has been made of the concept of complex, high‐risk PCI; it may refer to a group subset with specific patients’ and procedural’s characteristics that increase procedural complexity and patient risk,” the researchers wrote. “However, studies around complex, high‐risk PCI outcomes according to access site are limited to nonrandomized or small randomized controlled trials, highly selected cohorts, certain geographical areas or international surveys. Hence, the question of whether ‘radial first’ can achieve similar benefits in PCI outcomes in a complex, high‐risk PCI procedure remains unanswered.”
In a retrospective study, Mamas and colleagues analyzed data from 137,785 patients who underwent complex, high-risk PCI, using records from the British Cardiovascular Intervention Society dataset. Among those patients, 44.9% had PCI with transradial access. Researchers compared the baseline characteristics, trends and outcomes of complex, high-risk PCI procedures performed electively from 2006 to 2017 according to access site.
Researchers found that transradial access increased over time, from 14.6% in 2006 to 67% in 2017.
Patients who underwent PCI with transradial access were older, with a greater prevalence of previous stroke, hypertension, peripheral vascular disease and history of smoking.
Transradial access was used more frequently in most complex, high-risk PCI procedures, including for older adults (51.6%), those with chronic renal failure (52.6%), poor left ventricular function (47.6%), left main PCI (48%) and treatment for severe vascular calcification (50.3%); however, transfemoral access was more commonly used for patients with prior CABG, PCI to a chronic total occlusion and patients with LV support.
After adjustment for differences in clinical and procedural characteristics, transfemoral access was independently associated with higher odds for mortality (adjusted OR = 1.3; 95% CI, 1.1-1.7), major bleeding (aOR = 2.9; 95% CI, 2.3-3.4) and MACCE — in-hospital death, periprocedural MI or periprocedural stroke — after propensity-score matching (aOR = 1.2; 95% CI, 1.1-1.4). Researchers observed similar findings for multiple accesses, with adjusted ORs of 2.1 for mortality (95% CI, 1.5-2.8), 5.5 for major bleeding (95% CI, 4.3-6.9) and 1.4 for MACCE (95% CI, 1.2-1.7).
“Transradial access benefits were extended across all complex, high-risk PCI factors, including those where transfemoral access was commonly used,” the researchers wrote.
The researchers noted that wider adoption of transradial access among higher‐risk patients may potentially improve outcomes for those undergoing complex, high-risk PCI.
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