Effects of Radial Versus Femoral Artery Access in Patients With Acute Coronary Syndromes With or Without ST-Segment Elevation

Study Questions:

What is the relative benefit of radial access versus femoral access in patients with ST-segment elevation myocardial infarction (STEMI) and non–ST-segment elevation acute coronary syndrome (NSTE-ACS)?


The authors compared efficacy and bleeding outcomes in patients randomized to radial versus femoral access in the RIVAL (RadIal Vs femorAL access for coronary intervention trial) study by the presenting diagnosis. The presenting diagnosis was STEMI in 1,958 patients, and NSTE-ACS in 5,063 patients.


There was significant interaction between the presenting diagnosis (STEMI or NSTE-ACS) and the route of access, with the benefit of the radial approach either limited to or enhanced in the STEMI subgroup. In STEMI patients, radial access reduced the primary outcome (composite of death, myocardial infarction, stroke, non–coronary artery bypass graft–related major bleeding ) compared with femoral access (3.1% vs. 5.2%; hazard ratio [HR], 0.60; p = 0.026). No difference in the primary endpoint was noted in patients treated with either access approach in the NSTE-ACS cohort (3.8% vs. 3.5%, p = 0.49). In STEMI patients, radial access was associated with a reduction in the secondary endpoints of death/myocardial infarction/stroke (2.7% vs. 4.6%; HR, 0.59; p = 0.031), and all-cause mortality (1.3% vs. 3.2%; HR, 0.39; p = 0.006), with no difference in NSTE-ACS patients. When the analysis was restricted to patients undergoing primary percutaneous coronary intervention (PCI), mortality was reduced with radial access (1.4% vs. 3.1%; HR, 0.46; p = 0.041). Access site bleeding was lower with the radial approach in both STEMI and NSTE-ACS patients.


The authors concluded that a radial approach is associated with a lower mortality and morbidity in patients undergoing PCI for STEMI, but not in those with NSTE-ACS.


The authors presented an interesting subgroup analysis of a trial that overall was negative with respect to its primary outcome. The findings of reduced mortality with radial access in STEMI are interesting, and corroborate those demonstrated in the RIFLE-ACS trial. However, neither of the two trials was powered to demonstrate a mortality benefit in this cohort, and the findings could be simply related to random chance. While it would be ideal to have this hypothesis tested in an adequately powered randomized controlled trial, that is unlikely to happen in the near future. Radial access is increasingly being adopted by a growing number of operators and institutions, and it will be interesting to assess if this translates into an improvement in survival of patients undergoing PCI for STEMI.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and ACS

Keywords: Myocardial Infarction, Acute Coronary Syndrome, Stroke, Morbidity, Heart Conduction System, Cardiovascular Diseases, Femoral Artery, Coronary Artery Bypass, Angioplasty, Hemorrhage, Percutaneous Coronary Intervention

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