In 1992, Kiemeneij performed the first transradial coronary procedure, following Campeau’s description of that access in 1989. It’s been 30 years since that milestone in interventional cardiology. Over time, the number of procedures conducted with this approach has increased exponentially, and it is the main approach in most centers in different clinical scenarios.
Historically, the transradial approach (TRA) has been associated with lower rates of access-related bleeding and vascular complications compared with the transfemoral approach (TFA). However, results were inconclusive in some studies.
Gargiulo et al. recently presented at the European Congress of Cardiology the first large meta-analysis of pooled data of individual patients from high-quality randomized studies (as opposed to meta-analyses of studies). The aim of this work was to compare the TRA and TFA approaches among patients undergoing coronary angiography alone or with percutaneous coronary intervention (PCI), so as to determine whether the choice of approach changes mortality or bleeding rates.
Researchers conducted a search in MEDLINE, EMBASE, Cochrane, and other databases. The primary endpoint was 30-day all-cause mortality, and the co-primary endpoint was 30-day bleeding. Secondary endpoints included BARC bleeding, TIMI bleeding, myocardial-revascularization-surgery-related bleeding, need for transfusion, and stent thrombosis. Finally, the study also assessed the presence of the composite of major adverse cardiac and cerebrovascular events (MACCE), and the composite of net adverse clinical events (NACE) at 30 days.
A total of 1499 citations were screened. Of them, 22 were potentially eligible for subsequent analysis. The final selection listed 7 randomized studies, from which individual patient data were included.
Data were obtained from 21,600 patients: 49.9% were randomized to TRA and 50.1% to TFA; mean patient age was 63.9 years old, 31.9% of subjects were women, and the clinical presentation was predominantly acute (NSTEACS 48.6% and STEACS 46.2%). PCI was performed in 75.2% of the interventions.
There was a decrease in all-cause mortality with the TRA approach compared with TFA at 30 days (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.63-0.95; p = 0.012). When analyzing the subgroup of patients with hemoglobin <11g/dL, a more significant decrease was observed (HR: 0.35; 95% CI: 0.20-0.61; p < 0.001).
Major bleeding was lower in the TRA group at 30 days (odds ratio [OR]: 0.55; 95% CI: 0.45-0.67; p < 0.001), a benefit observed for all definitions of bleeding used.
When analyzing the MACCE composite, the TRA approach presented fewer events (OR: 0.89; 95% CI: 0.79-1.0; p = 0.047). Regarding NACE, fewer events were also observed (OR: 0.80; 95% CI: 0.72-0.89; p < 0.001).
Conclusions
The results of this meta-analysis of individual patient data showed with good certainty (regarding evidence) that the transradial approach was associated with lower mortality and lower bleeding rates, which in turn decreases MACCE and NACE at 30 days. Nevertheless, the risk of stroke, acute myocardial infarction, or stent thrombosis was not altered. These data can be extrapolated and validated for the population with acute coronary syndrome, which accounts for 95% of the patients included.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Impact on Mortality and Major Bleeding of Radial Versus Femoral Artery Access for Coronary Angiography or Percutaneous Coronary Intervention: a Meta-analysis of Individual Patient Data From Seven Multicenter Randomized Clinical Trials.
Font: Gargiulo, Giuseppe et al. “Impact on Mortality and Major Bleeding of Radial Versus Femoral Artery Access for Coronary Angiography or Percutaneous Coronary Intervention: a Meta-analysis of Individual Patient Data from Seven Multicenter Randomized Clinical Trials.” Circulation, 10.1161/CIRCULATIONAHA.122.061527. 29 Aug. 2022.
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