The Transradial Approach Continues to Be the Best for Primary PCI

The transradial approach has been associated to lower mortality and bleeding rates in patients receiving primary PCI for ST elevation MI. 

El acceso radial continúa siendo la mejor opción para la angioplastia primaria

This had been called into question by the recent SAFARI-STEMI, but after including its outcomes in a new meta-analysis, the scales tilted slightly in favor of the transradial approach vs. the transfemoral. 

The transradial approach is associated to lower all-cause mortality, major bleeding and vascular complications with no differences in terms of MI, stroke or procedure duration. The only point in favor of the transfemoral approach is fluoroscopy time. 

The European guidelines have given the transradial approach a class IA recommendation, over the transfemoral, for experienced operators. The American guidelines have not made this recommendation yet (seeing as their operators are more cautious than the European). However, the evidence is conclusive and sooner or later the American guidelines will also change. 

Prior studies comparing both access sites do not have enough statistical power to show significant differences in hard points such as mortality (even though the meta-analysis outcomes were conclusive). 

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The SAFARI-STEMI was not able to show differences in all-cause mortality or major bleeding at 30 days between access sites. 

This called for a meta-analysis, which included 16 randomized prior studies plus more recent SAFARI-STEMI to add up over 12000 patients.

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There were no significant differences in MI (RR 0.96; CI 95% 0.75-1.24), stroke (RR 1.37; CI 95% 0.82-2.29) or procedure duration. The only difference was shorter fluoroscopy time with the transfemoral approach. 

The difference was led by bleeding. For every 1000 transradial procedures operators will prevent 16 major bleeding events.

They also managed to prove that when the risk of bleeding is low, the difference in mortality rate disappears. This data tells the benefit in mortality of the transradial approach comes hand in hand with the lower bleeding rate. 

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The adoption percentage among operators is still quite heterogeneous. While the US is still around 50%, Europe is already at 90% in the context of PCI. 

The idea that a more difficult approach will waste precious time in a procedure where reperfusion velocity determines prognosis still holds operators back. This idea stems from the first observational studies, in times when operators were still inexperienced.  

Original Title: Meta-analysis of transradial vs transfemoral access for percutaneous coronary intervention in patients with ST elevation myocardial infarction.

Reference: Jhand A et al. Am J Cardiol. 2020; Epub ahead of print. doi: 10.1016/j.amjcard.2020.11.016.

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