JACC in a Flash | Radial Versus Femoral: Paradigm Time?
Periprocedural bleeding complications remain a major clinical burden for PCI. Recent research has focused on selecting the optimal access site, with the hope that radial access significantly reduces bleeding risk and access site complications. While the femoral approach is standard for PCI, large randomized clinical trials have demonstrated lower bleeding and complications risk, as well as better clinical benefit, with the radial approach in patients with acute coronary syndrome. The exact clinical benefit of radial compared to femoral approach is yet to be determined.
Ivo Bernat, MD, PhD, and colleagues designed the STEMI-RADIAL study to compare the clinical outcomes between radial and femoral approach in patients presenting with acute STEMI in high-volume, experienced centers proficient in both access sites.
Nearly 800 patients were enrolled in the randomized trial (348 in the radial group and 359 in the femoral group. Primary endpoint was cumulative incidence of major bleeding and vascular access site complications at 30 days; secondary endpoints included access-site crossover, contrast volume, duration of intensive care stay, and death at 6-month follow-up.
A greater percentage of patients in the femoral group experienced primary endpoint complications, compared to the radial group (1.4% vs. 7.2%; p = 0.0001). Femoral access patients also had greater rate of net adverse clinical events (4.6% vs. 11.0%; p = 0.0028). In terms of the secondary endpoints:
- a small percentage of patients (3.7%) crossed over from radial to femoral approach
- intensive care stay was significantly reduced in the radial group (2.5±1.7 vs. 3.0±2.9 days, p = 0.0038)
- contrast utilization was reduced (170±71 vs. 182±60 ml; p = 0.01)
- mortality in both groups were similar, though slightly higher in the femoral group at both time points (2.3% vs. 3.1% at 30 days; 2.3% vs. 3.6% at 6 months)
Ultimately, in patients with STEMI presenting within 12 hours of symptom onset, radial approach was associated with significant lower incidence of major bleeding, access site complications and superior net clinical benefit.
"There has been some reluctance to adopt radial access during primary PCI pointing out to potential problems like delaying reperfusion caused by longer patient preparation, longer time to gain vascular access and potentially more difficult catheters manipulation via the radial artery," Dr. Bernat and colleagues concluded. "Our study clearly demonstrates that for high-volume radial centers with experienced operators those issues are eliminated and are irrelevant."
"The perception that RA has a 'steep learning curve,' takes longer to perform, and is associated with higher radiation exposure have been addressed by multiple studies... [that are] helping shape the evidence base surrounding the relative benefits of radial versus femoral access," Robert Applegate, MD, of Wake Forest School of Medicine in Winston-Salem, North Carolina, wrote in an accompanying editorial. "As the authors of RADIAL-STEMI concluded, the results from these studies make a strong argument for considering a paradigm shift to radial access rather than femoral for primary PCI of STEMI."
Dr. Applegate noted several studies that disqualify the rumors about the radial approach's difficulty, and support the transition from preferred femoral to preferred radial access for primary PCI for STEMI, but stressed that interventional centers and operators must make a concerted effort to achieve proficiency in the radial approach.
Applegate RJ. J Am Coll Cardiol. 2014;63:973-5.
Bernat I, Horak D, Stasek J, et al. J Am Coll Cardiol. 2014;63(10):964-72.
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