Radial Versus Femoral Access for Coronary Angiography and Intervention in Patients With Acute Coronary Syndromes (RIVAL): A Randomised, Parallel Group, Multicentre Trial

Study Questions:

What is the benefit of using a radial versus femoral approach in patients undergoing coronary angiography or intervention?

Methods:

The RIVAL (RadIal Vs femorAL access for coronary intervention) trial investigators randomized 7,021 patients undergoing coronary angiography or intervention to a radial or femoral approach at 158 hospitals in 32 countries. The primary outcome was a composite of death, myocardial infarction, stroke, or non-coronary artery bypass graft (non-CABG)-related major bleeding at 30 days.

Results:

There was no difference in the occurrence of the primary endpoint between the two groups (3.7% in the radial access arm vs. 4.0% in the femoral access arm; hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.72-1.17; p = 0.50). There was a significant interaction for the primary outcome with benefit for radial access in the highest tertile volume radial centers (HR, 0.49; 95% CI, 0.28-0.87; p = 0.015), and in patients with ST-segment elevation myocardial infarction (STEMI) (HR, 0.60; 95% CI, 0.38-0.94; p = 0.026). There was no difference in the occurrence of death, myocardial infarction, or stroke at 30 days (3.2% vs. 3.2%; HR, 0.98; 95% CI, 0.76-1.28; p = 0.90). There was no difference in non-CABG-related major bleeding (0.7% vs. 0.9%; HR, 073; 95% CI, 0.43-1.23; p = 0.23). The radial approach was associated with a lower incidence of large hematoma (1.1% vs. 3.0%; HR, 0.40; 95% CI, 0.28-0.57; p < 0.0001) or pseudoaneurysm needing treatment (0.19% vs. 0.65%; p = 0.006).

Conclusions:

The investigators concluded that there was no difference in major outcomes among patients treated with radial access compared with those treated using femoral access, although radial access was associated with a reduction in access-related complications.

Perspective:

This study clearly demonstrates a reduction in access site complications with radial access, although this was not associated with a reduction in major bleeding or a reduction in major adverse events. The survival benefit seen in patients with STEMI is very interesting, but the trial was not powered for this, and it may be premature to consider this finding definitive. However, the overall results suggest good outcome with both femoral and radial access, but a clear reduction in access site complications with a radial approach supports wider uptake of this approach.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Myocardial Infarction, Acute Coronary Syndrome, Stroke, Coronary Angiography, Coronary Artery Bypass


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