Advertisement
Canadian Journal of Cardiology

Radial vs Femoral Access in ACS Patients Undergoing Complex PCI Is Associated With Consistent Bleeding Benefit and No Excess of Risks

      Abstract

      Background

      The comparative effectiveness of transradial (TRA) compared with transfemoral (TFA) access in acute coronary syndrome (ACS) patients undergoing complex percutaneous coronary intervention (PCI) remains unclear.

      Methods

      Among 8404 ACS patients in the Minimising Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX (MATRIX)—Access trial, 5233 underwent noncomplex (TRA: n = 2590; TFA: n = 2643) and 1491 complex (TRA: n = 777; TFA: n = 714) PCI. Co-primary outcomes were major adverse cardiovascular events (MACE, the composite of all-cause mortality, myocardial infarction, or stroke) and the composite of MACE and Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding (net adverse cardiovascular events [NACE]) at 30 days.

      Results

      Rates of 30-day MACE (HR 0.94, 95% CI 0.72-1.22) or NACE (HR 0.89, 95% CI 0.69-1.14) did not significantly differ between groups in the complex PCI group, whereas both primary end points were lower (HR 0.84, 95% CI 0.70-1.00; HR 0.83, 95% CI 0.70-0.98; respectively) with TRA among noncomplex PCI patients, with negative interaction testing (Pint = 0.473 and 0.666, respectively). Access-site BARC type 3 or 5 bleeding was lower with TRA, consistently among complex (HR 0.18, 95% CI 0.05-0.63) and noncomplex (HR 0.41, 95% CI 0.20-0.85) PCI patients, whereas the former group had a greater absolute risk reduction of 1.7% (number needed to treat: 59) owing to their higher absolute risk.

      Conclusions

      Among ACS patients, PCI complexity did not affect the comparative efficacy and safety of TRA vs TFA, whereas the absolute risk reduction of access-site major bleeding was greater with TRA compared with TFA in complex as opposed to noncomplex PCI.

      Résumé

      Contexte

      L'efficacité comparative de l'accès transradial (ATR) par rapport à l'accès transfémoral (ATF) chez les patients souffrant d'un syndrome coronarien aigu (SCA) et subissant une intervention coronarienne percutanée (ICP) complexe reste incertaine.

      Méthodes

      Parmi les 8404 patients atteints de SCA participant à l'essai MATRIX (Minimising Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX), 5233 ont subi une ICP non complexe (ATR : n = 2590; ATF : n = 2643) et 1491 une ICP complexe (ATR : n = 777; ATF : n = 714). Les principaux indicateurs de résultats étaient les événements cardiovasculaires indésirables majeurs (ECIM, composite de la mortalité toutes causes confondues, de l'infarctus du myocarde ou de l'accident vasculaire cérébral) et le composite des ECIM et des hémorragies de type 3 ou 5 selon le score du Bleeding Academic Research Consortium (BARC) (événements cardiovasculaires indésirables nets [ECIN]) à 30 jours.

      Résultats

      Les taux d'ECIM (Rapport des risques instantanés (RRI) 0,94, IC à 95 % 0,72-1,22) ou d'ECIN (RRI 0,89, IC à 95 % 0,69-1,14) à 30 jours n'ont pas différé de manière significative entre les groupes dans le groupe ICP complexe, alors que les deux critères d'évaluation primaires étaient inférieurs (RRI 0,84, IC à 95 % 0,70-1,00; RRI 0,83, IC à 95 % 0,70-0,98; respectivement) via l'ATR chez les patients ICP non complexes, avec un test d'interaction négatif (Pint = 0,473 et 0,666, respectivement). Les hémorragies de type 3 ou 5 du BARC au niveau du site d'accès étaient plus faibles via l'ATR, de manière constante chez les patients ayant subi une ICP complexe (RRI 0,18, IC à 95 % 0,05-0,63) et non complexe (RRI 0,41, IC à 95 % 0,20-0,85), alors que le premier groupe présentait une réduction du risque absolu plus importante de 1,7 % (nombre nécessaire à traiter : 59) en raison de son risque absolu plus élevé.

      Conclusions

      Chez les patients atteints de SCA, la complexité de l'ICP n'a pas eu d'incidence sur l'efficacité et la sécurité comparatives de l'ATR par rapport à l'ATF, tandis que la réduction du risque absolu d'hémorragie majeure au point d'accès était plus importante avec l'ATR qu'avec l'ATF dans les ICP complexes que dans les ICP non complexes.

      Graphical abstract

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Neumann F.-J.
        • Sousa-Uva M.
        • Ahlsson A.
        • et al.
        2018 ESC/EACTS guidelines on myocardial revascularisation.
        Eur Heart J. 2019; 40: 87-165
        • Mason P.J.
        • Shah B.
        • Tamis-Holland J.E.
        • et al.
        An update on radial artery access and best practices for transradial coronary angiography and intervention in acute coronary syndrome: a scientific statement from the American Heart Association.
        Circ Cardiovasc Interv. 2018; 11: e000035
        • Jolly S.S.
        • Yusuf S.
        • Cairns J.
        • et al.
        Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial.
        Lancet. 2011; 377: 1409-1420
        • Valgimigli M.
        • Gagnor A.
        • Calabró P.
        • et al.
        Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial.
        Lancet. 2015; 385: 2465-2476
        • Romagnoli E.
        • Biondi-Zoccai G.
        • Sciahbasi A.
        • et al.
        Radial versus femoral randomised investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Vs Femoral Randomised Investigation in ST-Elevation Acute Coronary Syndrome) study.
        J Am Coll Cardiol. 2012; 60: 2481-2489
        • Valgimigli M.
        • Frigoli E.
        • Leonardi S.
        • et al.
        Radial versus femoral access and bivalirudin versus unfractionated heparin in invasively managed patients with acute coronary syndrome (MATRIX): final 1-year results of a multicentre, randomised controlled trial.
        Lancet. 2018; 392: 835-848
        • Andò G.
        • Cortese B.
        • Russo F.
        • et al.
        Acute kidney injury after radial or femoral access for invasive acute coronary syndrome management: AKI-MATRIX.
        J Am Coll Cardiol. 2017; 69: 2592-2603
        • Giustino G.
        • Chieffo A.
        • Palmerini T.
        • et al.
        Efficacy and safety of dual antiplatelet therapy after complex PCI.
        J Am Coll Cardiol. 2016; 68: 1851-1864
        • Serruys P.W.
        • Takahashi K.
        • Chichareon P.
        • et al.
        Impact of long-term ticagrelor monotherapy following 1-month dual antiplatelet therapy in patients who underwent complex percutaneous coronary intervention: insights from the Global Leaders trial.
        Eur Heart J. 2019; 40: 2595-2604
        • Dangas G.
        • Baber U.
        • Sharma S.
        • et al.
        Ticagrelor with or without aspirin after complex PCI.
        J Am Coll Cardiol. 2020; 75: 2414-2424
        • Meijers T.A.
        • Aminian A.
        • van Wely M.
        • et al.
        Randomised comparison between radial and femoral large-bore access for complex percutaneous coronary intervention.
        JACC Cardiovasc Interv. 2021; 14: 1293-1303
        • Valgimigli M.
        • Landi A.
        Large-bore radial access for complex PCI.
        JACC Cardiovasc Interv. 2021; 14: 1304-1307
        • Valgimigli M.
        Design and rationale for the Minimising Adverse haemorrhagic events by TRANSRADIAL access site and systemic implementation of AngioX program.
        Am Heart J. 2014; 168 (45.e6): 838
        • Valgimigli M.
        • Frigoli E.
        • Leonardi S.
        • et al.
        Bivalirudin or unfractionated heparin in acute coronary syndromes.
        N Engl J Med. 2015; 373: 997-1009
        • Costa F.
        • van Klaveren D.
        • Feres F.
        • et al.
        Dual antiplatelet therapy duration based on ischemic and bleeding risks after coronary stenting.
        J Am Coll Cardiol. 2019; 73: 741-754
        • Coughlan J.J.
        • Aytekin A.
        • Ndrepepa G.
        • et al.
        Twelve-month clinical outcomes in patients with acute coronary syndrome undergoing complex percutaneous coronary intervention: insights from the ISAR-REACT 5 trial.
        Eur Heart J Acute Cardiovasc Care. 2021; 10: 1117-1124
        • Valgimigli M.
        • Landi A.
        Ischaemic and bleeding risk in patients with acute coronary syndrome undergoing complex percutaneous coronary intervention: is it time to REACT?.
        Eur Heart J Acute Cardiovasc Care. 2021; 10: 1125-1128
        • Chieffo A.
        • Burzotta F.
        • Pappalardo F.
        • et al.
        Clinical expert consensus document on the use of percutaneous left ventricular assist support devices during complex high-risk indicated PCI: Italian Society of Interventional Cardiology Working Group Endorsed by Spanish and Portuguese Interventional Card.
        Int J Cardiol. 2019; 293: 84-90
        • Burzotta F.
        • Russo G.
        • Ribichini F.
        • et al.
        Long-term outcomes of extent of revascularisation in complex high risk and indicated patients undergoing impella-protected percutaneous coronary intervention: report from the Roma-Verona Registry.
        J Interv Cardiol. 2019; 20195243913
        • Megaly M.
        • Karatasakis A.
        • Abraham B.
        • et al.
        Radial versus femoral access in chronic total occlusion percutaneous coronary intervention.
        Circ Cardiovasc Interv. 2019; 12: e007778

      Linked Article

      • Time to Ditch Transfemoral Access for Complex Percutaneous Coronary Intervention?
        Canadian Journal of Cardiology
        • Preview
          Few topics in interventional cardiology have received more fervent study than the radial-vs-femoral debate. There is now overwhelming evidence that transradial access (TRA) is associated with lower incidence of vascular complications and bleeding in patients undergoing percutaneous coronary intervention (PCI), and even mortality in the context of acute coronary syndromes (ACS).1,2 For this reason, TRA is recommended as the default access route for PCI by guidelines.3,4
        • Full-Text
        • PDF