Original title: Influence of Arterial Access Site Selection on Outcomes in Primary Percutaneous Coronary Intervention. Are the Results of Randomized Trials Achievable in Clinical Practice? Reference: Mamas A. Mamas et al. J Am Coll Cardiol Intv 2013. Article in press.
Antithrombotic therapy has improved the prognosis of patients with acute ST-segment elevation myocardial infarction by reducing ischemic events. However, this reduction has been achieved at the expense of a greater bleeding risk. A significant part of this bleeding is related to the access site.
This study included all patients undergoing PCI in the UK between 2006 and 2010. It analyzed a total of 46128 patients; the transfemoral access site was used in 28091 patients (60.9%) and the transradial access in 18037 patients (39.1%). In 2006 the transradial approach was used in 12.5% of procedures; by 2010, it had grown to 49.5% of procedures.
Patients who underwent transradial access PCI received glycoprotein IIb/IIIa and thrombus aspiration more frequently, while transfemoral access PCI patients saw more artery bypass graft, shock and balloon counterpulsation.
Mortality at a follow up of almost two years (13.6% vs 6.7%; p<0.0001) and mortality at 30 days (5.1% vs 6.7%; p<0.0001) were both significantly lower in the transradial access patients.
After a propensity score analysis to adjust all baseline characteristic differences, the transradial approach continued to show significantly lower mortality rates, less bleeding, less vascular complications and less MACCW events than the femoral access site.
Conclusion:
This analysis of patients treated by primary percutaneous coronary intervention in the United Kingdom over a 5-year period has shown that the transradial approach is associated to lower mortality rates compared to the transfemoral approach.
Editorial comment:
The transradial approach appears to be one of the greatest achievements in the history of cardiology. From a wider perspective, thrombolytics compared to placebo had reduced mortality in 25% of infarction patients. Afterwards, PCI compared to thrombolytics reduced mortality in approximately 40%. These reductions in mortality rates are of similar importance as the reduction rates achieved with transradial PCI that this study analyzed (29%) or as a recent meta analysis of randomized studies (48%).
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