Radial vs. Femoral Access in Acute Coronary Syndrome

Le May MR, Singh K, Wells GA.
Efficacy of Radial Versus Femoral Access in the Acute Coronary Syndrome: Is it the Operator or the Operation That Matters? JACC Cardiovasc Interv 2015;8:1405-1409.

The following are 10 points to remember about the efficacy of radial versus femoral access in patients with acute coronary syndrome (ACS):

  1. The conclusion reached by the authors of the MATRIX trial, stating that transradial access (TRA) reduces net adverse clinical outcomes as compared with transfemoral access (TFA) in patients with ACS undergoing invasive assessment, needs to be interpreted with caution.
  2. The analyses of the results clearly demonstrate that operator/center experience is a key variable influencing the measured outcomes.
  3. The interpretation of the culminated MATRIX trial results may be distorted, given the multiple interactions and the inclusion of two distinct patient populations.
  4. The MATRIX trial did not apply pharmaceutical strategies or report on the usage of vascular closing devices that may reduce bleeding.
  5. The MATRIX trial also did not report on cumulative radiation exposure, which should be an important risk factor incorporated into the efficacy evaluation of both access sites.
  6. A change in guidelines favoring TRA may not be appropriate for all patients, institutions, and cardiologists. It would be undesirable for skilled and well-established interventionalists who have been highly successful with TFA to change practice without the results of a trial specifically designed to resolve the debate.
  7. In some clinical situations, such as cardiogenic shock, proficiency at performing percutaneous coronary intervention (PCI) via the TFA could ensure better outcomes.
  8. It is important that interventional programs aim to ensure continued competency at performing the two approaches.
  9. Additional trials, particularly in the ST-segment elevation myocardial infarction population, are needed to resolve the debate on access site looking at mortality as a primary outcome, and should be conducted in centers where there is a reasonable balance in the centers’ experience at performing PCI via either access mode.
  10. It is from these appropriately designed future trials, the question of whether it is the “operator’s experience or the operation itself that matters,” and the question whether TRA is indeed superior to TFA performed by skilled operators can finally be answered.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Acute Heart Failure, Interventions and ACS

Keywords: Acute Coronary Syndrome, Cardiovascular Diseases, Hemorrhage, Myocardial Infarction, Percutaneous Coronary Intervention, Radiation, Risk Factors, Shock, Cardiogenic

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