Effectiveness and feasibility of transradial approaches for primary percutaneous coronary intervention in patients with acute myocardial infarction

doi:10.1016/S1007-4376(09)60068-X

Journal of Nanjing Medical University

Volume 23, Issue 4, July 2009, Pages 270-274

https://doi.org/10.1016/S1007-4376(09)60068-X Get rights and content

Abstract

Objective

To evaluate the efficacy and feasibility of the transradial approach for primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction(AMI).

Methods

195 patients with acute myocardial infarction were randomly divided into two groups according to the different PCI operation pathways. 105 cases were assigned to the transfemoral artery group and 90 cases to the transradial artery group. We analyzed the data from the two groups, including the achievement ratio of paracentesis, cannulation time, the time from local anesthesia to the first time balloon inflation, the time of the total procedure, achievement ratio of PCI, incidence rate of vascular complications, total duration of hospitalization, and the six-month follow-up results in both groups.

Results

Our results showed that the achievement ratio of arteriopuncture, cannulation time and the time from local anesthesia to the first time balloon inflation in the transradial and transfemoral groups were 98.9% vs. 100%, 3.15 ± 1.56 min vs. 2.86 ± 0.97 min, and 18.56 ± 4.37 min vs. 17.75 ± 3.21 min, respectively. These differences between the two groups were not statistically significant. The total operating time was 29.75 ± 4.38 min for the transradial group and 27.89 ± 3.95 min(P < 0.05) for the transfemoral group. The operation achievement ratio in the transradial group was 96.7%, and 96.2% in the transfemoral group. The incidence of puncture point complications was 2.2% in the transradial group and 11.4% in the transfemoral group, and this difference was significant. The duration of hospitalization was 10.56 ± 2.85 days for the transradial group and 13.78 ± 3.15 days(P < 0.05) for the transfemoral group. At the six-month follow-up, the rate of survival without cardiac event was 86.1% vs. 86.4% respectively in the transradial and transfemoral groups(P > 0.05).

Conclusion

The transradial approach was as effective as the transfemoral approach, and there were fewer puncture point complications as well as a shorter span of hospitalization in the transradial group. PCI via the transradial approach is safe, effective and feasible in patients with AMI.

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Cited by (37)

Radial vs. Femoral Access for Percutaneous Coronary Artery Intervention in Patients With ST-Elevation Myocardial Infarction
2021, Cardiovascular Revascularization Medicine
We aimed to compare the safety and efficacy of transradial vs transfemoral access for coronary angiography and intervention in patients presenting with ST-segment elevation myocardial infarction (STEMI) without cardiogenic shock.
PubMed, Embase and Cochrane Central were searched for randomized controlled trials (RCTs) comparing outcomes of STEMI patients who underwent transradial angiography (TRA) compared to transfemoral angiography (TFA). Our outcomes of interest were major adverse cardiac events (MACE), all-cause mortality, severe bleeding, access site bleeding, myocardial infarction, stroke, and major vascular complications. Summary statistics are reported as odds ratios (OR) with 95% confidence intervals (CI).
In a pooled analysis of 17 RCTs with 12,118 randomized patients, the use of transradial compared to transfemoral approach in STEMI patients without cardiogenic shock was associated with a significant reduction in MACE [OR 0.85 (95% CI 0.73–0.99; p = 0.04; NNT = 111; I² = 0%)] and all-cause mortality [OR 0.71 (95% CI 0.57–0.88; p < 0.01; NNT = 111; I² = 0%)]. Severe bleeding [OR 0.57 (95% CI 0.44–0.74; p < 0.01; NNT = 77; I² = 0%)], access-site bleeding [OR 0.39 (95% CI 0.26–0.59; p < 0.01; NNT = 67; I² = 24%)], and major vascular complications [OR of 0.31 (95% CI 0.17–0.55; p < 0.01; NNT = 125; I² = 0%)] were lower in TRA compared to TFA. There was no difference in stroke (0.6% vs 0.5%) or recurrent myocardial infarction (2.01% vs 2.02%) between the two approaches.
For coronary intervention in STEMI patients without cardiogenic shock, there is a clear mortality benefit with the TRA over TFA. Further studies are needed to see if this mortality benefit persists over the long-term.
Meta-Analysis of Transradial vs Transfemoral Access for Percutaneous Coronary Intervention in Patients With ST Elevation Myocardial Infarction
2021, American Journal of Cardiology
Citation Excerpt :
After excluding duplicates and studies that did not meet inclusion criteria, a total of 17 RCTs comparing TRA and TFA in STEMI-PCI were selected for the quantitative analysis (Figure 1). This meta-analysis included 17 RCTs with 12,018 patients, of which 5,958 underwent PCI using TRA and 6,060 using TFA in STEMI.3–16,19,21–23 Mean/median age of study population ranged from 52 to 71.4 years, and 76.6% were males, Table 1.
Transradial access (TRA) has emerged as an alternative to transfemoral access (TFA) for percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) patients. However, the rate of TRA adoption has been much slower in the acute coronary syndrome (ACS) patient population. This meta-analysis was conducted to assess clinical outcomes of TRA compared with TFA in STEMI patients undergoing PCI. A manual search of PubMed, EMBASE, Cochrane library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and recent major scientific conference sessions from inception to October 15th, 2019 was performed. Primary outcomes in our analysis were all-cause mortality and trial-defined major bleeding. Secondary outcomes included vascular complications, myocardial infarction, stroke, procedure, and fluoroscopy time. 17 randomized controlled trials (RCTs) (N = 12,018) met inclusion criteria. TRA was associated with lower all-cause mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.57 to 0.88), major bleeding (RR: 0.59, 95%CI: 0.45 to 0.77), and vascular complications (RR: 0.42, 95%CI: 0.32 to 0.56) compared with TFA. There was no difference in the incidence of myocardial infarction (MI), stroke, or procedure duration between the 2 groups. The difference in all-cause mortality between TRA and TFA was statistically nonsignificant when major bleeding was held constant. In conclusion, TRA was associated with lower risk of all-cause mortality, major bleeding, and vascular complications compared with TFA in STEMI patients undergoing PCI.
Radial versus femoral access for percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction: Trial sequential analysis
2020, American Heart Journal
Randomized controlled trials (RCTs) have yielded conflicting results about the impact of transradial access (TRA) versus transfemoral access (TFA) in patients with ST-segment elevation myocardial infarction (STEMI).
We performed a trial sequential analysis (TSA) of RCTs comparing TRA and TFA in patients with STEMI. The outcomes of interest were 30-day mortality, major bleeding, major adverse cardiovascular events (MACE), myocardial infarction (MI), stroke, and access site complications.
A total of 17 studies with 11,992 patients were included in the current TSA. The TRA group had lower 30-day mortality (risk ratio [RR] 0.72, 95% CI 0.58-0.90, P = .003), major bleeding (RR 0.62, 95% CI 0.49-0.79, P = .0001), MACE (RR 0.74, 95% CI 0.58-0.93, P = .01), and access site complications (RR 0.37, 95% CI 0.28-0.48, P < .00001). There was no difference in MI and stroke between the 2groups. Applying TSA boundaries, the z-curve for 30-day mortality, major bleeding, MACE and access site complications crossed the conventional and the TSA boundaries, indicating firm evidence for better outcomes in the TRA group. For MI and stroke, the z-curve failed to cross the conventional and the TSA boundaries for both outcomes, indicating lack of signals of benefit or harm.
In the current TSA, the available data from RCTs support improved 30-day mortality, major bleeding, MACE and access site complication rates in STEMI patients treated by PCI through the radial access.
Radial Versus Femoral Access for Coronary Interventions Across the Entire Spectrum of Patients With Coronary Artery Disease: A Meta-Analysis of Randomized Trials
2016, JACC: Cardiovascular Interventions
The aim of this study was to provide a quantitative appraisal of the effects on clinical outcomes of radial access for coronary interventions in patients with coronary artery disease (CAD).
Randomized trials investigating radial versus femoral access for percutaneous coronary interventions have provided conflicting evidence. No comprehensive quantitative appraisal of the risks and benefits of each approach is available across the whole spectrum of patients with stable or unstable CAD.
The PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for randomized trials comparing radial versus femoral access for coronary interventions. Data were pooled by meta-analysis using a fixed-effects or a random-effects model, as appropriate. Pre-specified subgroup analyses according to clinical presentation, in terms of stable CAD, non–ST-segment elevation acute coronary syndromes, or ST-segment elevation myocardial infarction were performed.
Twenty-four studies enrolling 22,843 participants were included. Compared with femoral access, radial access was associated with a significantly lower risk for all-cause mortality (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.59 to 0.87; p = 0.001, number needed to treat to benefit [NNTB] = 160), major adverse cardiovascular events (OR: 0.84; 95% CI: 0.75 to 0.94; p = 0.002; NNTB = 99), major bleeding (OR: 0.53; 95% CI: 0.42 to 0.65; p < 0.001; NNTB = 103), and major vascular complications (OR: 0.23; 95% CI: 0.16 to 0.35; p < 0.001; NNTB = 117). The rates of myocardial infarction or stroke were similar in the 2 groups. Effects of radial access were consistent across the whole spectrum of patients with CAD for all appraised endpoints.
Compared with femoral access, radial access reduces mortality and MACE and improves safety, with reductions in major bleeding and vascular complications across the whole spectrum of patients with CAD.
Transradial vs Transfemoral Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction: A Systemic Review and Meta-analysis
2016, Canadian Journal of Cardiology
Citation Excerpt :
In the Radial vs Femoral Access for Coronary Angiography or Intervention (RIVAL) and Radial vs Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome (RIFLE-STEACS) trials, 7%-12% of patients were treated with rescue PCI.20,21 Seven trials limited follow-up to the duration of index hospitalization only.11,22-26 The OCEAN RACE trial reported in-hospital outcomes for all measures except mortality, which was reported up to maximum of 891 days.12
The objective of this meta-analysis to evaluate safety and efficacy of transradial vs the transfemoral approach for primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients.
Randomized controlled trials that compared the transfemoral vs the transradial approach in STEMI patients who underwent PCI were searched in PubMed, Embase, CENTRAL, Cumulative Index to Nursing and Allied Health Literature, and clinicaltrials.gov. Random effect models were used to pool effect sizes.
Sixteen trials, comprising data from 9726 patients, were included in the meta-analysis. All-cause mortality (risk ratio [RR], 0.68; 95% confidence interval [CI], 0.54-0.85; relative risk reduction [RRR], 32.8%; I² = 0), major bleeding (RR 0.56; 95% CI, 0.42-0.74; RRR, 48.1%; I² = 0), access site bleeding (RR, 0.38; 95% CI, 0.29-0.50; RRR, 63.9%; I² = 0), major adverse cardiovascular events (RR, 0.80; 95% CI, 0.68-0.94; RRR, 19.3%; I² = 0), and length of hospital stay (standardized mean difference, −0.38 days; 95% CI, −0.46 to −0.31 days) were significantly lower with the transradial compared with the transfemoral approach. The greatest reduction in major bleeding was found in the subgroup with trials recruiting only primary PCI participants compared with varying proportions of rescue PCIs. Glycoprotein IIb/IIIa inhibitor use and cross-over rates did not have a significant association with outcome measures in the subgroup analysis. Incidence of stroke was numerically greater with the transradial approach but did not achieve statistical significance (RR, 1.22; 95% CI, 0.56-2.66; I² = 0). Overall statistical heterogeneity (I²) was very low except for length of hospital stay.
The transradial approach for PCI in STEMI patients significantly reduced all-cause mortality, major and access site bleeding, major adverse cardiovascular events, and length of hospital stay. Difference in stroke incidence was not statistically significant with the transradial vs the transfemoral approach.
L’objectif de cette méta-analyse vise l’évaluation de l’innocuité et de l’efficacité de l’approche transradiale vs l’approche transfémorale pour réaliser l’intervention coronarienne percutanée (ICP) primaire chez les patients atteints d’un infarctus du myocarde (IM) avec sus-décalage du segment ST.
Les essais cliniques aléatoires qui comparaient l’approche transradiale vs l’approche transfémorale chez les patients atteints d’un IM avec sus-décalage du segment ST qui subissaient une ICP étaient recherchés dans PubMed, Embase, CENTRAL, Cumulative Index to Nursing and Allied Health Literature et clinicaltrials.gov. Les modèles à effets aléatoires étaient utilisés pour regrouper les tailles de l’effet.
Seize essais comprenant les données de 9726 patients étaient pris en compte dans la méta-analyse. La mortalité toutes causes confondues (risque relatif [RR], 0,68; intervalle de confiance [IC] à 95 %, 0,54-0,85; réduction du risque relatif [RRR], 32,8 %; I² = 0), l’hémorragie grave (RR, 0,56; IC à 95 %, 0,42-0,74; RRR, 48,1 %; I² = 0), l’hémorragie au site d’accès (RR, 0,38; IC à 95 %, 0,29-0,50; RRR, 63,9 %; I² = 0), les événements cardiovasculaires indésirables majeurs (RR, 0,80; IC à 95 %, 0,68-0,94; RRR, 19,3 %; I² = 0) et la durée du séjour à l’hôpital (différence moyenne standardisée, −0,38 jour; IC à 95 %, −0,46 à −0,31 jours) étaient significativement moindres par l’approche transradiale que par l’approche transfémorale. La plus grande réduction de l’hémorragie grave était observée dans le sous-groupe des essais recrutant seulement les participants ayant subi une ICP primaire par rapport à ceux aux proportions diverses des ICP de sauvetage. L’utilisation de l’inhibiteur de la glycoprotéine IIb/IIIa et les taux croisés ne montraient pas une association significative avec les mesures de résultats de l’analyse en sous-groupes. L’incidence de l’accident cérébral vasculaire était plus grande du point de vue du nombre par l’approche transradiale, mais n’était pas statistiquement significative (RR, 1,22; IC à 95 %, 0,56-2,66; I² = 0). L’hétérogénéité statistique globale (I²) était très faible, excepté la durée du séjour à l’hôpital.
L’approche transradiale de l’ICP chez les patients atteints d’un IM avec sus-décalage du segment ST réduisait significativement la mortalité toutes causes confondues, l’hémorragie grave et l’hémorragie au site d’accès, les événements cardiovasculaires indésirables majeurs et la durée du séjour à l’hôpital. La différence dans l’incidence de l’accident cérébral vasculaire n’était pas statistiquement significative entre l’approche transradiale vs l’approche transfémorale.
Radial Access Reduces Mortality in Patients with Acute Coronary Syndromes Results from an Updated Trial Sequential Analysis of Randomized Trials
2016, JACC: Cardiovascular Interventions
The authors sought to investigate whether the cumulative evidence coming from randomized studies has reached the necessary power to consider radial access as a bleeding avoidance strategy that reduces mortality and ischemic endpoints in patients with acute coronary syndromes (ACS).
Studies in ACS patients have reached conflicting conclusions about the impact of radial access in improving ischemic outcomes in addition to the established bleeding benefit.
English-language publications and abstracts of major cardiovascular meetings until October 2015 were scrutinized. Study quality, patient characteristics, procedural data, and outcomes were extracted. Data were pooled in random effects meta-analyses with classic and trial sequential techniques. Trial sequential analysis combines the a priori information size calculation needed to allow for clinically meaningful statistical inference with the adjustment of thresholds for which results are considered significant.
Seventeen studies, encompassing data from 19,328 patients, were pooled. Radial access was found to reduce mortality (relative risk [RR]: 0.73; 95% confidence interval [CI]: 0.60 to 0.88; p = 0.001), major adverse cardiovascular events (RR: 0.86; 95% CI: 0.77 to 0.95; p = 0.005), and major bleeding (RR: 0.60; 95% CI: 0.48 to 0.76; p < 0.001). Multiple sensitivity analyses showed consistent results, and trial sequential analysis suggested firm evidence for a meaningful reduction in mortality with radial access.
Radial access reduces mortality compared with femoral access in ACS patients undergoing invasive management. This benefit is paralleled by consistent reductions in major adverse cardiovascular events and major bleeding, supporting radial access as the default strategy for cardiac catheterization in patients with ACS.

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Research PaperEffectiveness and feasibility of transradial approaches for primary percutaneous coronary intervention in patients with acute myocardial infarction

Abstract

Objective

Methods

Results

Conclusion

Ann Thorac Surg

Int J Cardiol

Am Heart J

JACC Cardiovasc Intervent

Effect of tirofiban plus clopidogrel and aspirin on primary percutaneous coronary intervention via transradial approach in patients with acute myocardial infarction

Chin Med J (Engl)

Decreased complication rates using the transradial compared to the transfemoral approach in percutaneous coronary intervention in the era of routine stenting and glycoprotein platelet IIb/IIIa inhibitor use: A large single-center experience

Am Heart J

Reduced vascular complications and length of stay with transradial rescue angioplasty for acute myocardial infarction

Catheter Cardiovasc Interv

Research Paper
Effectiveness and feasibility of transradial approaches for primary percutaneous coronary intervention in patients with acute myocardial infarction