Is radial approach the gold standard for PCI?

Abstract

Consider this scenario. A 65 year old patient hospitalized with a troponin positive acute coronary syndrome (ACS) is initially managed with intensive antithrombotic therapy. Angiography is performed via the femoral artery, demonstrating a tight thrombus containing lesion in the left anterior descending artery that involves the first diagonal branch. Percutaneous coronary intervention (PCI) is performed, with a stent implanted into the left anterior descending artery, utilising a kissing balloon procedure to achieve an excellent final result. After this successful and uneventful procedure, the patient is transferred back to the cardiology ward. The following day the patient is noted to have a low blood pressure and complains of groin discomfort. Inspection reveals an extensive haematoma at the femoral puncture site. A large and expanding haematoma is demonstrated by ultrasound examination with an associated fall in hemoglobin to 7.2 g/dL. An immediate transfusion of 3 units of blood is administered and vascular surgical repair is required. Is this a rare, inconvenient, benign and unavoidable component of contemporary ACS management? The MORTAL study, published in this edition of HEART (1), complements an extensive and rapidly evolving literature that can help to answer these questions.