Transradial versus transfemoral percutaneous coronary intervention in acute myocardial infarction: Systematic overview and meta-analysis

doi:10.1016/j.ahj.2009.08.022

American Heart Journal

Volume 158, Issue 5, November 2009, Pages 814-821

https://doi.org/10.1016/j.ahj.2009.08.022 Get rights and content

Background

Although transradial percutaneous coronary intervention (TRPCI) is widely applied for percutaneous procedures, its safety in the setting of ST-segment elevation (STEMI) is controversial. Our aim was to assess the safety and efficacy of TRPCI versus transfemoral PCI in the context of treating patients suffering acute myocardial infarction with STEMI.

Methods

Randomized, case-control, and cohort studies comparing access-related complications were analyzed. Our objective was to determine if radial access reduces major bleeding and thereby reduces death and ischemic events compared to femoral access in this setting. A fixed-effects model was used with random effects for sensitivity analysis.

Results

Twelve studies involving 3324 patients were identified. Transradial PCI reduced major bleeding compared to transfemoral PCI (P = .0001), and significant reductions were found in the composite of death, myocardial infarction, or stroke (P = .001). Mortality reduction showed a significant toward benefit in the case of TRPCI (2.04% vs 3.06%, OR 0.54 [95% CI 0.33-0.86], P = .01). The fluoroscopic time was longer, and access site crossover was more frequent for TRPCI (P = .001, P < .00001, respectively).

Conclusions

Transradial PCI reduces the risk of periprocedural major bleeding and major adverse events in the STEMI setting.

Section snippets

Search strategy

We performed a systematic review of the available literature according to the MOOSE guidelines for the conduct of meta-analyses of observational studies.¹⁷ Relevant studies published between January 1993 and August 2009 were identified from MEDLINE, SCOPUS, the Web of Science with Conference Proceedings, and the Cochrane Central Register of Controlled trials using a search strategy that combined text word and MeSH heading. Search keywords included various combinations of the following terms:

Search results and study selection

Our search detected 213 citations. These included editorials, reviews, letters, or articles regarding other aspects of the radial approach. There were 62 observational studies investigating the feasibility and safety of the radial approach in a series of patients. Moreover, we found 13 studies comparing the radial and femoral approaches in a cohort of patients that included both elective and acute cases without reporting separate outcomes regarding the different settings. Twelve studies were

Discussion

The present meta-analysis found that transradial coronary intervention is highly effective and safe in the setting of acute MI. We demonstrated a significant benefit of using radial access for PCI in MI with respect to major bleeding as well as in MACE. These findings were consistent in the setting of primary and rescue PCI.

Bleeding events have been demonstrated to be associated with an increased risk of MACE including death and recurrent ischemic events in multiple studies.13, 14, 31 Although

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Cited by (152)

Society of Interventional Radiology Quality Improvement Standards on Radial Artery Access
2021, Journal of Vascular and Interventional Radiology
Citation Excerpt :
Since then, the prevalence of using TRA for coronary procedures has increased significantly, and, as of 2015, the European Society of Cardiology guidelines recommend radial access over transfemoral access (intraarterial recommendation) for coronary angiography and intervention (2). The interest in TRA has been driven by multiple prospective randomized trials, meta-analyses, and retrospective cardiology studies demonstrating significant benefits of TRA compared to transfemoral access (3), including but not limited to: patient preference (4), decreased access site complications in general (5–8), and, for elderly patients (9,10), decreased overall complications and decreased mortality (11–14). Interventionalists in other specialties have been slower to adopt TRA, but recent publications by vascular surgeons (15–17), neurointerventionalists (18–22), and interventional radiologists (23–47) indicate that TRA is being used across a variety of procedures to treat many medical conditions outside of the heart.
Shared Decision-Making in Femoral Versus Radial Cardiac Catheterization
2019, American Journal of Cardiology
Shared decision-making is a strategy to assist with patient involvement in medical decisions. One of its pillars is patient knowledge and understanding of the risks and benefits associated with specific procedures. We studied patient knowledge about transradial (TRA) and transfemoral (TFA) cardiac catheterization. A prospective study was conducted in 100 patients hospitalized following diagnostic and therapeutic cardiac catheterization—TRA in 71% of patients and remaining TFA. All patients were presented a standard balanced informed consent outlining risks and benefits. Following catheterization, patients were verbally administered an 11-item open-ended questionnaire to assess knowledge of cardiac catheterization and the associated risks and benefits. A patient knowledge index (PKI) was developed with 1 point given for: identifying the procedure; correctly describing the procedure; identifying at least 1 risk of TRA; and/or TFA; and at least 1 benefit of TRA; and/or TFA. Maximum PKI score was 6. The mean PKI score was 2.6 ± 1.1. A PKI score ≥4 was observed in 21% of patients with only 1 patient obtaining the maximum 6 points. Over 80% of patients were unable to recall procedure risks provided at the time of informed consent. The majority of patients were unable to discriminate between TRA and TFA risks and benefits, PKI 2.52 versus 2.60, respectively (p = 0.718). On multivariate analysis, higher education levels were correlated with increased PKI scores (odds ratio = 0.65, p = 0.014) whereas black race was associated with lower PKI scores (odds ratio = −0.48, p = 0.045). In conclusion, patient retention of information from the informed consent was low. The majority of patients had no preference or deferred to their physician's expertise when deciding TRA compared with TFA. This study identifies challenges with implementing shared decision-making and the need for improved patient education and involvement regarding cardiac catheterization.
Administration of Rotaglide™ solution for treating refractory severe radial artery spasm: A case report
2018, Cardiovascular Revascularization Medicine
Severe radial artery spasm is a complication of transradial cardiac catheterization. We describe a case of severe radial artery spasm causing catheter entrapment. The spasm was refractory and resistant to intra-arterial vasodilators, systemic vasodilators, and moderate sedation. Rotaglide™ (Boston Scientific, Marlborough, MA) solution via continuous infusion was delivered through the catheter and then the sheath, resolving the spasm and allowing the removal of the catheter and sheath without injury to the radial artery.
Patent haemostasis prevents radial artery occlusion in patients with an acute coronary syndrome
2017, International Journal of Cardiology
A haemostatic technique that maintains radial artery flow (“patent haemostasis”) following transradial catheterization reduces rates of radial artery occlusion (RAO) in patients with stable coronary disease. It is unclear whether this benefit extends to patients with an acute coronary syndrome (ACS).
Patients undergoing inpatient transradial catheterization for an ACS were prospectively enrolled in a consecutive cohort study (n = 300). Radial haemostasis was obtained using standard radial compression (cohort 1; n = 150) or patent haemostasis (cohort 2; n = 150). An end-of-case activated clotting time (ACT) was recorded and radial artery patency assessed within 24 hours of sheath removal by reverse Barbeau's test.
The incidence of RAO was 16.0% following standard radial compression and 5.3% following patent haemostasis (p = 0.003). Univariate predictors of RAO were patent haemostasis (OR 0.30; [0.13–0.68], p = 0.004), hyperlipidaemia (OR 0.46; [0.21–0.98], p = 0.04), history of current smoking (OR 2.86; [1.3–6.0], p = 0.015) and longer procedure times (OR 1.03/additional minute; [1.01–1.05], p = 0.003). There was no association between the end-of-case ACT and RAO (OR 1.00; [0.9–1.01] p = 1.00). After adjusting for covariates, patent haemostasis reduced the risk of RAO by 70% compared to standard compression (OR 0.30; [0.12–0.77], p = 0.12). The c-statistic for model discrimination was 0.79 (95% CI [0.71–0.86], p < 0.001). Inverse probability treatment weighted analysis also confirmed patent haemostasis as an independent predictor of reduced RAO (OR 0.38 [0.15–0.95], p = 0.039).
Patent haemostasis is highly effective in preventing early RAO in patients with ACS.
Barriers for transradial coronary angiography and interventions in 2016
2017, Cardiovascular Revascularization Medicine
Training the next generation of invasive cardiologists: Feasibility of implementing a trans-radial access program at an academic hospital
2016, Cardiovascular Revascularization Medicine
Slow adoption of trans-radial access (TRA) for left heart catheterization (LHC) in the U.S. may be related to concerns about procedural complexity and a steep learning curve. However, TRA acceptance among novice operators remains poorly characterized.
We initiated a 1-year TRA learning period among lower-risk outpatients, followed by a “radial-first” policy for all LHC patients beginning year 2. By year 3, all fellows prospectively collected diagnostic LHC data as part of a quality improvement study. TRA procedural characteristics were compared with patients undergoing trans-femoral access for the 3 months prior to the TRA program, and trends over time were evaluated.
Between 7/2009 and 6/2012, we identified 960 patients undergoing LHC via TRA by 23 rotating cardiology fellows supervised by 5 interventional cardiologists. When evaluated against the 160 trans-femoral comparator patients, TRA patients had lower procedural success through the initial access site (88% vs. 99%, p < 0.001) and longer fluoroscopy times (9.5 [5.8–15.9] vs. 6.5 [3.1–12.7] min, p < 0.001), with similar contrast volumes and fewer catheters used. Despite tackling more complex patients during years 2–3, there were improvements in fluoroscopy times, catheter utilization, contrast volumes, and procedural success rates over time (all p < 0.001).
The dedicated adoption of TRA by an academic catheterization laboratory demonstrated improvements in efficiency and resource utilization over a relatively short period of time. Additional exposure to TRA during training may help facilitate acceptance of this approach among the next generation of invasive cardiologists.
When initiating a trans-radial access program for cardiac catheterization at an academic training hospital, procedural success rates were lower and fluoroscopy times were higher than traditional trans-femoral access. Nonetheless, other procedural variables were similar between the 2 approaches, and improvements over time were consistent with the learning curves reported among experienced cardiologists in prior studies. Exposure to trans-radial access during training may help facilitate acceptance of this approach among the next generation of invasive cardiologists.

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Clinical InvestigationInterventional CardiologyTransradial versus transfemoral percutaneous coronary intervention in acute myocardial infarction: Systematic overview and meta-analysis

Background

Methods

Results

Conclusions

Section snippets

Search strategy

Search results and study selection

Discussion

J Am Coll Cardiol

Am Heart J

Am Heart J

Am Heart J

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Control Clin Trials

Rev Esp Cardiol

Am J Cardiol

Percutaneous transradial artery approach for coronary stent implantation

Cathet Cardiovasc Diagn

Right radial access for PTCA: a prospective study demonstrates reduced complications and hospital charges

J Invasive Cardiol

Rescue percutaneous coronary intervention using transradial arterial access with glycoprotein IIb/IIIa inhibitor eptifibatide therapy initiated post-fibrinolysis

J Invasive Cardiol

Effects and safety of intracoronary thrombectomy using transradial application of the PercuSurge distal balloon protection system in patients with early or recent myocardial infarction

Cardiology

Safety, feasibility and efficacy of transradial primary angioplasty in patients with acute myocardial infarction

Ital Heart J

Clinical Investigation
Interventional Cardiology
Transradial versus transfemoral percutaneous coronary intervention in acute myocardial infarction: Systematic overview and meta-analysis