Rotational atherectomy is a very important tool in the treatment of heavily calcified and non-dilatable lesions. Historically, transfemoral access has been the gold standard due to a perceived need for large-bore guidewire catheters in order to use spheroids for proper debulking.

Nowadays, rotational atherectomy has evolved towards a technique that aims to modify plaque for subsequent complete successful balloon dilatation, rather than complete debulking (which was the objective a few years ago). This shift in the technique allows for the use of smaller spheroids and, in turn, guidewire catheters that can be used in the radial artery.

Read also: “Transradial Access and Early Discharge in Percutaneous Interventions”.

Between 2005 and 2014, a total of 8622 patients underwent rotational atherectomy in the United Kingdom. In 3069 of these procedures, physicians used a transradial access and in 5553, a transfemoral access.

Propensity scores were calculated in order to balance out the differences between populations.

Read also: “Though on the Rise, the Transradial Approach to Primary PCI Remains Underused”.

The rates of death at 30 days (the primary endpoint for this study) were 2.2% with a transradial access vs. 2.3% with a transfemoral access (p = 0.76). Not only was transradial access associated with equivalent mortality rates, but also with similar procedural success rates (odds ratio [OR]: 1.04; p = 0.73) and similar rates for major cardiac and cerebrovascular events (OR: 1.05; p = 0.72), when compared with those for patients in whom transfemoral access was used. The clear advantages of transradial access were observed in lower rates of in-hospital major bleeding (OR: 0.62; p = 0.04) and lower rates of access-site complications (OR: 0.05; p = 0.004).

Conclusion

This is the real-life study that has included the largest group of patients with rotational atherectomy. In this population, transradial access offered similar rates of mortality and technical success, but significantly lower rates of minor bleeding and vascular complications, when compared with transfemoral access.

Editorial

The absence of benefit in terms of mortality may reflect the fact that most patients included were chronic and stable.

Despite traditional interventional conceptions, rotational atherectomies through transradial access were carried out without any problems.

A 6-French guidewire catheter easily allows for 1.25- or 1.5-mm spheroids, thus providing a spheroid to artery ratio of 0.5-0.6 for most vessels. Spheroid size is mostly aimed at modifying plaque and breaking calcium concentric rings, in almost all cases. Should a more aggressive ablation be necessary, with 1.75- or 2-mm spheroids, physicians could directly use a 7-French guidewire catheter, supported by most radial arteries.

Original title: Radial Versus Femoral Access for Rotational Atherectomy. A UK Observational Study of 8622 Patients.

Reference: Jonathan Watt et al. Circ Cardiovasc Interv. 2017 Dec;10(12).

We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.