• Transradial PCI: 'Slightly Safer' Based on Moderate Evidence Meta-analysis largely supports 'radial first' strategy

    Radial access for percutaneous coronary intervention (PCI) appears safer on the whole than the femoral alternative, a meta-analysis suggested.

    Even though neither radial nor femoral access held an advantage when it came to myocardial infarction or stroke, the study published online in JACC: Cardiovascular Interventions showed that radial access was tied to lower rates of adverse events, including:

    • All-cause mortality (1.55% versus 2.22% for femoral access, odds ratio 0.71, 95% CI 0.58-0.87)
    • Major adverse cardiac events (5.56% versus 6.67%, OR 0.84, 95% CI 0.75-0.94)
    • Major bleeding (1.07% versus 2.07%, OR 0.53, 95% CI 0.42-0.65)
    • Major vascular complications (0.24% versus 1.12%, OR 0.23, 95% CI 0.16-0.34)

    Furthermore, “the beneficial effects of radial access on clinical outcomes are largely consistent across stable or unstable presentation as well as type of acute coronary syndrome,” according to Giuseppe Ferrante, MD, PhD, of Humanitas Clinical and Research Center in Milan, Italy, and colleagues.

    “These findings support the use of radial access as the default approach for coronary angiography followed by PCI in the whole spectrum of patients with coronary artery disease undergoing invasive management and strongly support a change in the ‘femoral first’ paradigm to a ‘radial first’ approach,” they concluded, as has “been suggested by multiple individual studies and meta-analyses over the course of the last 20 years. However, the radial approach has also been challenged as being the technically more demanding procedure and as such requiring longer procedure time, greater radiation; and a steep learning curve.”

    John A. Bittl, MD, of Munroe Regional Medical Center in Ocala, Fla., wrote in an accompanying editorial that the radial approach cannot be a universal strategy, likening this thinking to the “‘emperor’s new clothes,’ a fallacy that no one really believes but everyone is willing to accept because so many people keep saying that it is true.”

    “Although the introduction of radial access for PCI has been a major advance, this approach is not ideal for every procedure or every practitioner,” he said. “There are many senior interventional cardiologists who know femoral anatomy intimately, have performed tens of thousands of transfemoral PCIs safely, and get frustrated during transradial PCI by the occasional aortic arch that directs catheters into the descending aorta.”

    Furthermore, “not every patient is a candidate for transradial PCI. Patients with unknown bypass graft anatomy, upper-extremity hemodialysis accesses, small radial arteries, abnormal Allen or oximetry tests, need for large transfemoral devices or hemodynamic support are not favorable candidates for the transradial approach.”

    “These groups represent a small proportion of patients undergoing PCI in contemporary practice,” Bittl nonetheless conceded.

    The meta-analysis pooled data from 24 studies, with a total of 22,843 patients thought to be suitable for either approach.

    Its authors acknowledged that their study may have suffered from possible heterogeneity and publication bias, despite a lack of statistical evidence suggesting so. Additionally, bleeding complications were classified with different scales across the studies included.

    “No sensitivity analysis eliminates the sobering fact that several excellent individual randomized controlled trials in the current overview did not meet their prospectively defined primary endpoints to demonstrate superiority of transradial PCI,” Bittl added.

    The editorialist, however, did agree with the investigators that the data provide “moderately strong evidence that transradial PCI is slightly safer than transfemoral PCI.”

    As for the timing of wider adoption of radial access PCI, he suggested it will come down to time — and to a larger extent, money.

    “In the U.S. transradial PCI will continue to gradually replace transfemoral approaches as older practitioners retire, but transradial PCI would replace transfemoral PCI more quickly if the radial approach could be reimbursed at a higher rate than the transfemoral approach,” he wrote.



    Ferrante and Bittl reported no relevant conflicts of interest.

    Valgimigli disclosed receiving institutional grants from The Medicines Company and Terumo for the MATRIX trial.


    JACC: Cardiovascular Interventions


    Ferrante G, et al “Radial vs femoral access for coronary interventions across the entire spectrum of patients with coronary artery disease: a meta-analysis of randomized trials” JACC Cardiovasc Interv 2016.


    JACC: Cardiovascular Interventions


    Bittl JA “Why radial access is better” JACC Cardiovasc Interv 2016.

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