Original title: Radial Versus Femoral Access for Primary Percutaneous Interventions in ST-Segment Elevation Myocardial Infarction Patients. A Meta-Analysis of Randomized Controlled Trials. Reference: Wassef Karrowni et al. J Am Coll Cardiol Intv 2013;6:814–23.

Bleeding is the most frequent in-hospital complication of PCI, and it is clearly associated with adverse events that include death.   STEMI patients require emergency revascularization as well as an aggressive antiplatelet and antithrombotic therapy that will make them more susceptible to bleeding. Since bleeding events are strongly associated to access site, the radial approach is an attractive strategy where bleeding risks should often be counterbalanced with a longer procedure time, which is a significant factor in the context of PCI.

This meta-analysis included 12 randomized studies that evaluated the outcomes of radial vs. femoral access for PCI in 5055 patients (2492 radial access vs. 2562 femoral access patients). The use of IIbIIIa glycoprotein inhibitors was common to all studies and with similar rates in both branches. Crossover from one access site to the other was more frequent for the radial approach (4.6%) compared to the femoral (1.1%).

A significant reduction of mortality risk was observed in the radial group compared to the femoral group (2.7% vs. 4.7%; OR 0.55, 95% IC 0.4 to 0.76; p<0.001) associated with a similar reduction in major bleeding (1.4% vs. 2.9%; OR 0.51, 95% IC 0.31 to 0.85; p<0.05). Relative risk of access site bleeding also decreased significantly (radial 2.1% vs. femoral 5.6%; OR 0.35, 95% IC 0.25 a 0.50; p<0.001). Stroke and MI risk were similar between both approaches.

Conclusion:

This meta-analysis outcomes show a reduction in mortality and bleeding favorable to the radial approach compared to the femoral approach in STEMI patients receiving PCI. 

Editorial Comment

All studies analyzed did not include patients in cardiogenic shock with the exception for the RIFLE-STEACS , which did not show difficulties in using the radial approach. PCI could be performed by radial approach in unstable patients, and the femoral approach could be reserved for counter pulsation balloon procedures, to mention an example. 

Procedure time resulted 1.5 minutes longer than the average in the radial group (95% IC 0.33 to 2.70; p=0.01). Although this point was frequently objected by femoral access advocates, it seems unimportant even in the context of PCI.

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