Original title: Full conversion from transfemoral to transradial approach for percutaneous coronary interventions results in a similar success rate and a rapid reduction of in-hospital cardiac and vascular major events. Reference: Vincent Dangoisse et al. EuroIntervention 2013;9:345-352.

Although the transfemoral approach has clear disadvantages when it comes to bleeding complications, it continues to be the preferred approach to PCI in most centers across the globe. Increasing evidence proves that bleeding, transfusion requirements and vascular complications are associated with higher mortality rates; consequently, many centers now prefer the transradial approach. 

This study is a good example of this conversion, where a center went from 100% of transfemoral (TFA) PCI in 2002 to 98 transradial (TRA) in 2007. During the five year conversion, all prospective results from all coronary angioplasty procedures comparing transfemoral vs. transradial approach in one single center, were registered. 

3600 angioplasty procedures were analyzed (1928 TFA and 1672 TRA). Results showed similar mortality and stroke rates but with a higher infarction rate with TFA (3.6% vs. 2.3%, p=0.023). The most significant difference was observed in transfusion and vascular emergency surgery rates, where TRA showed greater advantage (0.2% vs 1.5%, p<0.001). 

However, bleeding events not related to the vascular access site saw similar results (0.7% vs 0.9%, p=ns). For this cohort, the mean fluoroscopy time resulted 42 seconds higher with TRA (504 seg vs 546 seg, p=0.036) and 10 additional ml of contrast material were required, on average (226±99 ml vs 217±108 ml, p<0.001). Crossover was required only in 1.3% of procedures (in most cases, after having tried both radial arteries).

Conclusion:

TFA to TRA conversion in this center was relatively fast and safe, and had no significant impact in PCI success rate. Locally, this conversion translated into a significant reduction in Net Adverse Clinical (NACE) Events (death, infarction, stroke, emergency CABG, bleeding and transfusions).

Editorial Comment:

TRA use was also associated with more frequent prescription of downstream glycoprotein IIb/IIIa inhibitors (23.7% versus 7.4% for TFA, p<0.001) that may be explained by the operators’ different  perception of the risk/benefit ratio (greater benefit with less bleeding risk  with TRA approach). Despite this significant difference in the use of IIb/IIIa, bleeding events not related to vascular access saw similar results. The difference in infarction rates in favor of the transradial approach can be explained by the use of IIb/IIIa only partially and should be interpreted in the context of an observational study in one single center. Fluoroscopy and contrast volume differences are influenced by the first years of transition and the learning curve. 

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