Although using the radial artery as the access point for percutaneous coronary intervention (PCI) has been linked to reduced bleeding compared to use of the femoral artery, only a small number of high-risk myocardial infarction patients who undergo emergency PCI undergo treatment in this way, according to a study published Dec. 21 in JACC: Cardiovascular Interventions.

Using data from ACC’s CathPCI Registry, researchers examined records of 9,494 myocardial infarction patients who underwent emergency PCI after failed thrombolytic therapy. Among the patients who received rescue angioplasty, 14 percent had their procedure performed via radial access, while 86 percent were treated with femoral access. Radial access was associated with significantly less bleeding, but no differences in mortality were found. The researchers also observed a “risk-treatment paradox,” since the patients chosen for radial access were actually at a lower predicted risk for bleeding than those chosen for the femoral access approach.

To determine if other factors were influencing these results, researchers used gastrointestinal bleeding, which shouldn’t have differed between the groups, as a negative control. They found that patients in the radial access group had fewer gastrointestinal bleeding incidents, suggesting that unmeasured confounders, such as patient characteristics used in deciding access approach, may have influenced adjusted outcomes.       

Jay Giri, MD, the study’s senior author, points out that the findings, “demonstrate the likely presence of treatment-selection bias regarding access site choice that cannot be easily adjusted in observational datasets.”

"This study makes it clear that radial access is used much less than femoral,” notes Spencer B. King III, MD, MACC, editor-in-chief of JACC: Cardiovascular Interventions. “The reason seems to be that operators comfortable with femoral access are reluctant to change. The best results from radial approach are among those operators who do the majority of their cases this way. Adopting a less familiar approach safely is the challenge for many who have established good results with femoral approaches. As recently trained operators take on more of the workload this is likely to change.”

In an accompanying editorial, Ehtisham Mahmud, MD, FACC, and Mitul Patel, MD, FACC, add that moving forward, there is a need for more research to better understand these findings and for strategies to increase radial access for patients at the highest risk of bleeding after PCI.

Keywords: Angioplasty, Femoral Artery, Hemorrhage, Myocardial Infarction, Percutaneous Coronary Intervention, Radial Artery, Selection Bias, Thrombolytic Therapy

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