Clinical Outcomes Following Radial Versus Femoral Artery Access in Primary or Rescue Percutaneous Coronary Intervention in Scotland: Retrospective Cohort Study of 4534 Patients

Study Questions:

What are the short- and medium-term outcomes following radial and femoral artery access for primary or rescue percutaneous coronary intervention (PCI)?

Methods:

This was a Scotland-wide retrospective cohort study of 4,534 patients undergoing primary or rescue PCI in Scotland between April 2000 and March 2009 using the Scottish Coronary Revascularization Register. Radial and femoral artery access were based on the reported final access site. The main outcome measures were procedural success; periprocedural complications; 30-day and 1-year mortality, myocardial infarction, or stroke; and long-term mortality. Cox proportional-hazards regression was used to determine the unadjusted and adjusted hazard ratio for survival in radial versus femoral access patients, with radial access forming the referent population.

Results:

Use of the radial approach increased from no cases in 2000 to 924 (80.5%) in 2009 (p < 0.001). Patients in whom the radial approach was used were more likely to be male (p = 0.041) and to have multiple comorbidities (p < 0.001), including hypertension (p < 0.001) and left ventricular dysfunction (p < 0.001). They were less likely to have renal impairment (p = 0.017), multivessel coronary disease (p = 0.001), and cardiogenic shock (p < 0.001). In multivariable analyses, use of radial artery access was associated with greater procedural success (adjusted odds ratio [OR], 1.89; 95% confidence interval [CI], 1.26-2.82; p = 0.002) and a lower risk of any complications (adjusted OR, 0.67; 95% CI, 0.51-0.87; p = 0.001) or access site bleeding complications (adjusted OR, 0.21; 95% CI, 0.08-0.56; p = 0.002), as well as a lower risk of myocardial infarction (adjusted OR, 0.66; 95% CI, 0.51-0.87; p = 0.003) or death within 30 days (adjusted OR, 0.51; 95% CI, 0.04-0.52; p < 0.001). The differences in myocardial infarction and death remained significant up to 9 years of follow-up.

Conclusions:

The authors concluded that use of the radial artery for primary or rescue PCI is associated with improved clinical outcomes.

Perspective:

This study reports that compared with femoral access, primary and rescue PCI undertaken using radial access had a higher rate of procedural success and a lower risk of periprocedural, 30-day, and 1-year adverse events. In common with most observational studies, a limitation of this study was the lack of data regarding planned initial access route, crossover rate, and inability to adjust for confounders such as door-to-balloon time. While there will remain individual patients in whom femoral access is preferable, use of the radial approach may be preferable in a significant proportion of patients. Additional randomized prospective studies are indicated to further solidify the assertion that radial artery access should be the most preferred initial approach.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Acute Heart Failure, Hypertension

Keywords: Odds Ratio, Outcome Assessment (Health Care), Myocardial Infarction, Stroke, Radial Artery, Scotland, Femoral Artery, Comorbidity, Coronary Disease, Percutaneous Coronary Intervention, Shock, Cardiogenic, Confidence Intervals, Ventricular Dysfunction, Left, Hypertension, Hemorrhage


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