Transradial intervention (TRI) may be associated with decreased PCI-associated bleeding across different risk groups, according to a study published recently in Circulation: Cardiovascular Interventions.

Ty J. Gluckman, MD, FACC, et al., performed a retrospective analysis of PCIs from 18 facilities across a single health system to compare the impact of three bleeding avoidance strategies (BAS) – procedural anticoagulation with bivalirudin (BIV), TRI, and use of a vascular closure device (VCD). The researchers used ACC's CathPCI Registry bleeding model to assess bleeding risk, with procedures stratified into six categories based on bleeding risk (first, second, third quartiles, 75th to 90th, 90th to 97.5th, and top 2.5th percentiles). The primary endpoint was post PCI bleeding, based on CathPCI Registry definition of suspected or confirmed bleeding events within 72 hours of PCI.

Out of a total of 74,953 PCIs, 9.4% used no BAS, 12% used BIV alone, 20.8% used TRI alone, and 26.8% used VCD alone. In addition, 5.4% used BIV and TRI and 25.6% used BIV and VCD. Age, gender, body mass index, race/ethnicity, and rates of diabetes, prior PCI, prior myocardial infarction, and prior stroke were similar across all bleeding risk groups.

Overall, the bleeding rate was 4.4%. Bleeding was highest in procedures using no BAS (9.6%) and lowest in those using BIV and TRI (1.7%) As bleeding risk increased, crude bleeding rates increased from 0.2% to 2.2% in the first quartile to 23% to 39% in the top 2.5th percentile. The researchers also looked at the odds of bleeding between BAS in each risk category. The odds of bleeding were lower across all risk groups for BIV and VCD (95% confidence interval [CI], first quartile, 0.36 (0.18-0.72) to top 2.5th percentile, 0.50 (0.32-0.78) and TRI alone (95% CI, first quartile, 0.15 (0.06-0.38) to top 2.5th percentile, 0.49 (0.28-0.86). Factors limiting use of TRI, such as renal failure, shock, cardiac arrest and mechanical circulatory support, were present in ≤10% of procedures below the 90th percentile of bleeding risk.

According to the researchers, the findings provide "strong support for TRI, without the addition of BIV, as the preferred BAS." Although quality improvement initiatives focused on use of BAS have led to a reduction in bleeding rates, the difference in bleeding rates based on BAS suggests a different approach is needed, they write, adding, "Simply put, it is not just about using any BAS – it is about using the right BAS."

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Vascular Closure Devices, Quality Improvement, Percutaneous Coronary Intervention, Hemorrhage, Stroke, Registries, National Cardiovascular Data Registries, Myocardial Infarction, CathPCI Registry

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