Radial access outperforms femoral access for complex PCI, but questions persist
Transradial access (TRA) for complex percutaneous coronary intervention (PCI) is associated with a significant reduction in bleeding or vascular complications compared to transfemoral access (TFA), according to new findings published in JACC: Cardiovascular Interventions.
“Currently, the femoral artery is the preferred access site for complex PCI, despite the related increased risk for bleeding and vascular complications with adverse clinical outcomes,” wrote lead author Thomas A. Meijers, MD, a cardiologist at Isala Heart Center in the Netherlands, and colleagues. “The most important reason to apply TFA is the preferred use of large-bore guiding catheters, which is associated with higher procedural success in chronic total occlusion PCI. Also, because of the smaller size of the radial artery, the resulting sheath-to-artery mismatch might lead to more vascular and bleeding complications, thereby restricting the use of the radial artery for large-bore access.”
However, they explained, improved catheters have been introduced—including a thin-walled radial introducer sheath—that could potentially help TRA overcome its previous limitations and become the preferred option for complex PCI. To take a closer look at this possibility, the group compared outcomes of TRA and TFA for complex PCI with large-bore access.
The study included nearly 400 adult patients who underwent PCI for complex coronary lesions from March 2019 to March 2020. The mean patient age was 69 years old, and 81% were men.
While 50% of the cohort underwent PCI with TRA, the other 50% underwent PCI with TFA. The treatment choices were made at random, and patient characteristics between the two groups were all similar. Follow-up data was gathered 30 days after each patient was discharged.
The study’s primary endpoint was defined as “access site-related clinically significant bleeding or vascular complications requiring intervention at discharge.” Its secondary endpoint, meanwhile, was procedural success.
Overall, the authors reported, the primary endpoint occurred in 19.1% of TFA patients and just 3.6% of TRA patients. The procedural success rates were closer—89.2% for TFA patients and 86% for TRA patients.
When it came to duration, contrast volume and radiation dose—three key factors to track for any complex PCI patient—the team observed no significant differences. However, the major adverse cardiovascular event (MACE) rate after 30 days was 6.7% for TRA patients and 2.6% for TFA patients, a gap that was close to being statistically significant.
Key questions remain
The team’s analysis was also accompanied by an editorial written by Marco Valgimigli, MD, PhD, and Antonio Landi, MD, two specialists from the Cardiocentro Ticino Institute in Switzerland. Valgimigli and Landi praised the study, noting that it raises key questions about treating complex PCI patients, but they also highlighted certain limitations, including the relatively small sample size, the difference in MACE rates and the lack of data related to renal outcomes.
“The current study by Meijers et al. demonstrated that radial access is technically feasible and safer in complex PCI,” the two authors wrote. “Alongside this, interventional cardiologists should maintain high expertise in both radial and femoral access especially in complex interventions, basing access site selection on individual clinical and technical/procedural features. In this regard, the numerical imbalance in MACE events in favor of femoral access will most likely raise concern among many ‘femoral believers’ that radial access may not adequately support complex intervention. Therefore, further randomized adequately powered trials of radial access versus femoral access in complex intervention are warranted.”
Read the original analysis here. The editorial is available here.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.