Transradial vs. Transfemoral Access Among Patients With AMI and Cardiogenic Shock Undergoing PCI

Transradial access among patients with acute myocardial infarction (AMI) and cardiogenic shock undergoing PCI was associated with significantly lower rates of in-hospital adverse outcomes when compared to transfemoral access, irrespective of mechanical circulatory support use, according to a study published June 26 in JACC: Cardiovascular Interventions.

Dhruv Mahtta, DO, MBA, et al., included 35,944 patients (median age 68 years, 34.2% female) with AMI and cardiogenic shock undergoing PCI from ACC’s CathPCI Registry between April 2018 and June 2021. Researchers assessed outcomes and site variation using multivariable logistic regression and inverse probability weighting models and employed a falsification analysis using nonaccess site related bleeding.

They found that 25.6% of all PCI procedures analyzed were performed via transradial access, with the proportion of these procedures increasing over the duration of the study: 22.0% in the second quarter of 2018 and 29.1% in the second quarter of 2021 (p-trend <0.001). They noted that 20.9% of all sites used transradial access in <2% of cases while 1.9% of all sites used the approach in >80% of cases, indicating significant variation among institutions.

When evaluating in-hospital outcomes following PCI, patients undergoing transradial vs. transfemoral access were observed to have significantly lower adjusted incidence of major bleeding (odds ratio [OR], 0.71; 95% CI, 0.67-0.76), mortality (OR, 0.73; 95% CI, 0.69-0.78), vascular complications (OR, 0.67; 95% CI, 0.54-0.84) and new dialysis (OR, 0.86; 95% CI, 0.77-0.97), with no difference in nonaccess site-related bleeding (OR, 0.93; 95% CI, 0.84-1.03).

Sensitivity analyses identified similar benefit of transradial access among patients without arterial cross-over, and the authors observed no significant interactions between PCI performed via transradial access with mechanical circulatory support and in-hospital outcomes.

“The survival benefit associated with [transradial access PCI] over [transfemoral access PCI] among patients without [cardiogenic shock] has largely been attributed to reduction in major bleeding events,” write the authors. “Our analysis demonstrated that even among patients with [AMI and cardiogenic shock], the use of [transradial access PCI] was associated with significantly lower odds of major bleeding and in-hospital mortality.”

In an accompanying editorial comment, Bimmer E. Claessen, MD, PhD, and Elma Peters, MD, add, “Despite the obvious but inevitable limitations that come with observational research, the present study by Mahtta, et al., adds further robustness to the available evidence that [transradial access], when feasible, is safer than [transfemoral access], including in the setting of [AMI and cardiogenic shock].”

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

Keywords: Registries, Hemorrhage, Myocardial Infarction, Shock, Cardiogenic, Renal Dialysis, Logistic Models, Incidence, Percutaneous Coronary Intervention, Odds Ratio, CathPCI Registry, National Cardiovascular Data Registries

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