Death, bleeding lower but stroke higher with radial access PCI vs. femoral access
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Key takeaways:
- Radial access PCI use increased since 2013, with lower mortality and bleeding vs. femoral access PCI.
- However, there was a small increased risk for stroke with radial access that was not previously reported.
Use of radial access for PCI has increased greatly in the U.S. over the last decade and is associated with lower risk for mortality, bleeding and nonfatal vascular complications compared with a transfemoral approach, a speaker reported.
However, there was a credible elevated risk for stroke with radial access compared with femoral access PCI, according to a large real-world study presented at the Society for Cardiovascular Angiography and Interventions Scientific Sessions.
“The U.S. has lagged behind the rest of the world in the adoption of radial access, and we wanted to evaluate this because there wasn’t any contemporary data beyond 2015,” Reza Fazel, MD, FSCAI, structural and interventional cardiologist and health services researcher with joint appointments at Beth Israel Deaconess Medical Center and Cape Cod Hospital, said during a press conference.
Using the National Cardiovascular Data Registry CathPCI registry, Fazel and colleagues evaluated temporal trends in radial access PCI among 6.7 million PCIs performed between 2013 and 2022.
A second goal of the present study was to assess impact of radial compared with femoral access on clinical outcomes after PCI among 2.2 million PCIs done between 2018 and 2022.
Overall, 40.4% of PCIs performed between 2013 and 2022 utilized radial access.
Radial access increased 2.8 fold, being utilized in 20.3% of PCIs in 2013 and 57.5% in 2022 (P for trend < .001).
Radial access PCI increased significantly for the treatment of STEMI, non-ST elevation ACS (NSTEACS) and non-ACS (P for all < .001).
The absolute risk difference for death (0.15%; 95% CI, 0.2 to 0.1; P < .001), major access site bleeding (0.64%; 95% CI, 0.68 to 0.6; P < .001) and other vascular complications (0.21%; 95% CI, 0.23 to 0.18; P < .001) significantly favored radial access compared with femoral access PCI. However, Fazel reported an increased risk for ischemic stroke with radial access PCI (absolute risk difference, 0.05%; 95% CI, 0.03-0.08; P < .001).
Increased risk for stroke with radial access “has not been seen in any of the major randomized trials,” Fazel said. “There was a meta-analysis in 2021 that included contemporary data, and there was a signal for a trend toward increased stroke with radial access, but it didn’t reach statistical significance.”
Incidence of gastrointestinal bleeding, the falsification endpoint, was not significantly different between radial and femoral access PCI (absolute risk difference, 0%; 95% CI, 0.03 to 0.03; P = .893).
The researchers noted a gradient of benefit from radial access PCI, with patients presenting with STEMI deriving larger benefits from radial access compared with femoral access than those with NSTEACS and non-ACS.
The absolute risk difference for death significantly favored radial access for patients with STEMI (0.43%; P < .001) and non-ST elevation ACS (0.09%; P = .001), but not non-ACS (P = .143). The absolute risk difference favored radial access PCI all three patient subgroups with regard to major access site bleeding and vascular complications (P for all < .001).
Moreover, the increased risk for stroke with radial access was observed in both the STEMI (absolute risk difference, 0.09%; P =.018) and NSTEACS groups (absolute risk difference, 0.04%; P = .022) but not the non-ACS group (P = .082).
“We’ve seen over the past decade a substantial change in how PCIs are performed in the U.S. with radial access becoming the dominant approach and, in real-world practice,” Fazel said during the presentation. “We were able to confirm the same benefit that’s been seen in randomized trials with a smaller population, that radial access leads to lower mortality, lower major bleeding and lower vascular complications.
“We included non-STEACS patients, which previously had not been a part of the randomized trial picture,” he said. “Importantly, this finding of increased stroke risk with radial access is small but increased ... but we believe that using the methodology of the analysis, we can create a causal inference with radial access having this increased risk of stroke.”
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Fazel R, et al. Featured clinical research part 1. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; May 2-4, 2024; Long Beach, California.
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