If the radial artery is the new standard of care in primary percutaneous coronary intervention, why is most intervention done by the femoral approach? | Heart

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If the radial artery is the new standard of care in primary percutaneous coronary intervention, why is most intervention done by the femoral approach?

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Vascular access for primary PCI
Karim Ratib
Published on: 16 June 2011
Transradial primary PCI: this is the time for awareness.
Bernardo Cortese
Published on: 16 June 2011

Published on: 16 June 2011
Vascular access for primary PCI
- Karim Ratib, Specialist Registrar
- Other Contributors:
  Helen C. Routledge, Mamas A. Mamas, Doug Fraser, James Nolan
We read with great interest the recent article by Patterson and Foale relating to access site selection for cardiac procedures(1). The authors discuss a series of published trials comparing the use of radial and femoral access sites, and conclude that there is not sufficient evidence to justify a shift from femoral to radial access for most cardiac procedures.
The radial artery access site was introduced into c...
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We read with great interest the recent article by Patterson and Foale relating to access site selection for cardiac procedures(1). The authors discuss a series of published trials comparing the use of radial and femoral access sites, and conclude that there is not sufficient evidence to justify a shift from femoral to radial access for most cardiac procedures.
The radial artery access site was introduced into contemporary cardiac practice over 20 years ago. Over this time period considerable effort has been put into comparing radial and femoral access in observational and randomised trials. The observational studies suggest that radial access can be employed with safety, reduces costs, is preferred by patients, and may reduce mortality. Meta analysis of the randomised studies confirms unequivocally that employing radial access results in a reduction in vascular and bleeding complications(2). Since bleeding rates are highest in acute coronary syndrome patients undergoing PCI who are exposed to arterial punctures in the context of potent antithrombotic regimes, the beneficial influence of employing radial access is likely to be maximised in this subpopulation. This is supported by a meta-analysis of randomised and observational trials in STEMI patients which demonstrates a reduction in mortality and MACE with no significant effect on procedural duration or door to balloon time(3). The recently published RIVAL study provides welcome additional information from a large randomised trial of over 7000 ACS patients. This confirms that the use of radial access in STEMI is associated with a significant and clinically important reduction in mortality(4). The study also provides evidence that experienced radial operators can reduce mortality in a broader population of ACS and stable patients.
The authors raise a number of issues relating to technical aspects of performing radial procedures. Initially, operators had limited knowledge relating to anatomical and technical issues that are pertinent to the use of the radial access, and equipment was primitive. Over the last 20 years extensive procedural and technical development has occurred and success rates for well trained skilled radial operators in contemporary practice are comparable to those achieved by femoral operators(5). Experienced operators routinely employ radial access for haemodynamically unstable patients, re-puncture the same site on multiple occasions, access the right heart from a simultaneous upper limb venous puncture, image bypass grafts, overcome anatomical obstacles with ease and achieve comparable procedure duration. The reported increase in radiation exposure is a learning curve phenomenon that has no relevance to established practitioners(6). In 2011 use of the radial access site does not impose technical limitations in interventional practice.
In common with other aspects of catheterisation procedures, arterial access site practice has evolved over the last 50 years. In the UK the most recent national PCI audit demonstrates that radial access is now utilised in almost 50% of PCI procedures. The rate of change is rapid (in 2005 the rate was 10%) and shows no sign of slowing. Internationally this trend is occurring in many countries. This change in practice is driven by cardiologists (and increasingly patients) evaluation of the large volume of safety data that exists. We endorse the recent comments by Di Mario et al, and recommend that interventional cardiologists ensure that they are well trained in all access sites, but employ the radial artery for most procedures(7).
1. Patterson T, and Foale RA. If the radial artery is the new standard of care in primary percutaneous coronary intervention, why is most intervention done by the femoral approach? Heart. 2011, Apr;97(7):521 -2.
2. Jolly SS, Amlani S, Hamon M, Yusuf S, and Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J. 2009, Jan;157(1):132-40.
3. Vorobcsuk A, K?nyi A, Aradi D, Horv?th IG, Ungi I, Louvard Y, and Kom?csi A. Transradial versus transfemoral percutaneous coronary intervention in acute myocardial infarction Systematic overview and meta- analysis. Am Heart J. 2009, Nov;158(5):814-21.
4. Jolly SS, Yusuf S, Cairns J, Niemel? K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial [Internet]. The Lancet. 2011, Apr 2011;Available from: http://linkinghub.elsevier.com/retrieve/pii/S0140673611604042
5. Freestone B, and Nolan J. Transradial cardiac procedures: the state of the art. Heart. 2010, Jun;96(11):883-91.
6. Lo TS, Zaman AG, Stables R, Fraser D, Oldryod KG, Hildick-Smith D, and Nolan J. Comparison of operator radiation exposure with optimized radiation protection devices during coronary angiograms and ad hoc percutaneous coronary interventions by radial and femoral routes. Eur Heart J. 2008, Jun 17;(29):2180-2187.
7. Di Mario C, and Viceconte N. Radial angioplasty: worthy RIVAL, not undisputed winner [Internet]. The Lancet. 2011, Apr 4;Available from: http://linkinghub.elsevier.com/retrieve/pii/S0140673611604698
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 16 June 2011
Transradial primary PCI: this is the time for awareness.
- Bernardo Cortese, MD
Letter regarding the article "If the radial artery is the new standard of care in primary percutaneous coronary intervention, why is most intervention done by the femoral approach?"
Because things take some time to change, but we're on the right lane. I must disagree however with the conclusions of this recently published point of view, where T Patterson and RA Foale comment on the performance of trans-radial pr...
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Letter regarding the article "If the radial artery is the new standard of care in primary percutaneous coronary intervention, why is most intervention done by the femoral approach?"
Because things take some time to change, but we're on the right lane. I must disagree however with the conclusions of this recently published point of view, where T Patterson and RA Foale comment on the performance of trans-radial primary percutaneous coronary interventions (PCI) (1). After a brief history of the technique and an overview of the enormous advantages derived by its use (fewer bleedings, lower incidence of composite endpoint of death, stroke and myocardial infarction), they hit and stab and snap. In conclusion, they say that urgent PCI should not be performed via the transardial route.
That's weird. In our opinion, the advantages of this route of intervention unfold just during primary PCI. We'll try to prove that: -Any coronary intervention (especially if emergent) can be performed with a 6 Fr introducer, so the radial route is practicable in >90% of cases. -During primary PCI, it is common to use more potent antithrombotic drugs (i.e., abciximab, prasugrel), that are associated with an higher bleeding risk. -In this journal, SL Heterington et al recently published the results of a study performed in a single high-volume centre and involving 1051 patients undergoing primary PCI (2). Procedures performed with the transradial route, apart from warranting fewer bleedings if compared to the transfemoral one, was discovered to reduce in-hospital major adverse cardio and cerebrovascular events, door-to-balloon and symptom-to-balloon time, contrast load and radiation dose. Interestingly, if operators at the beginning of the study preferred the transfemoral route in the 80% of cases, at the end only 20% of them were treated with the big artery! -In case of cardiogenic shock, the transradial route should be preferred because it avoids dual femoral puncture and interference with the balloon counterpulsation.
We radialists are well aware that this route of intervention requires a big expertise and a steep learning curve. After a good level of expertise however, it is plain how this technique does not increase procedural and fluoroscopy time and access site crossover rate is very low. Moreover costs for the healthcare system are lower and, importantly, patient outcome is similar or superior without any inconvenience (3). Patients are happy to "walk" outside the cath lab, if undergone elective procedures. But the real advantages do occur in case of primary PCI!
References
(1) Patterson T, Foale RA. If the radial artery is the new standard of care in primary percutaneous coronary intervention, why is most intervention done by the femoral approach? Heart 2011;97:521-22. (2) Hetherington SL, Adam Z, Morley R et al. Primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction: changing patterns of vascular access, radial versus femoral artery. Heart 2009;95:1612-18. (3) Amoroso G, Kiemeneij F. Transradial access for primary percutaneous coronary intervention: the next standard of care? Heart 2010;96:1341-44.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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