Access Site and Outcomes in Chronic Total Occlusion PCI

Study Questions:

What is the association between access site and outcome of patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI)?

Methods:

The authors used data from the British Cardiovascular Intervention Society to assess outcomes of 26,807 elective CTO PCI procedures performed in England and Wales between 2006 and 2013. The predictors and implications of access-site choice were assessed using multivariate logistic regression.

Results:

Femoral artery (FA) access decreased from 84.6% in 2006 to 57.9% in 2013. Femoral access was associated with use of dual access (odds ratio [OR], 3.89; 95% confidence interval [CI], 3.45-4.32), CrossBoss/Stingray (OR, 1.87; 95% CI, 1.43-2.12), intravascular ultrasound (OR, 1.32; 95% CI, 1.21-1.53), and microcatheter use (OR, 1.18; 95% CI, 1.03-1.39). There was a strong association between FA access and the number of CTO devices used (p = 0.001 for trend). Patients undergoing femoral access were more likely to have access-site complications (1.5% vs. 0.5%; p < 0.001), periprocedural myocardial infarction (0.5% vs. 0.2%; p = 0.037), major bleeding (0.8% vs. 0.2%, p < 0.001), transfusion (0.4% vs. 0%; p < 0.001), and 30-day death (0.6% vs. 0.1%; p = 0.002).

Conclusions:

Femoral access is associated with a greater likelihood of complications in patients undergoing CTO PCI.

Perspective:

Femoral access, especially in the United Kingdom, is infrequently used for PCI in contemporary practice and is usually reserved for more complex cases (as was evident in this study). It is likely that the worse outcome seen in this group reflects the increased complexity, and thus, may not be entirely modifiable by switch to radial access. Some of the bleeding complications could be prevented by meticulous access technique and careful post-access management, and these strategies should be incorporated into routine practice for these high-risk cases.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: Angioplasty, Blood Transfusion, Coronary Occlusion, Femoral Artery, Hemorrhage, Myocardial Infarction, Percutaneous Coronary Intervention, Treatment Outcome, Ultrasonography


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