Access Site Complication Rate Unchanged Despite Increase in Transradial PCI Use

No significant decrease in vascular access-site complications (VASC) was noted despite an increase in the use of transradial percutaneous coronary intervention (PCI), according to research published in JACC Cardiovascular Interventions.

To evaluate trends in vascular access and complications, researchers analyzed data for patients who underwent PCI between January 1, 2013 and December 31, 2017 (N=153,123) at participating centers through the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. According to the site used to perform the majority of the PCI, patients were grouped as individuals who underwent transfemoral PCI (n=98,247) and ones who underwent transradial PCI (n=54,876).

Vascular access-site complications were defined as composite endpoints including hematoma, loss of limb, surgical repair, acute thrombosis, retroperitoneal hematoma, femoral neuropathy, pseudoaneurysm, or arteriovenous fistula. Vascular complications that occurred at the secondary access site were ascribed to the group defined by primary access sites but as secondary vascular complications.

In 2013, 74.1% (n=22,407) of patients underwent transfemoral PCI, and 25.9% (n=7817) of patients underwent transradial PCI. In 2017, 54.8% (n=16,977) of patients underwent transfemoral PCI, and 45.2% (n=14,023) of patients underwent transradial PCI. The unadjusted rate of femoral VASC increased from 1.6% to 2.3% (P <.001), radial VASC increased from 0.2% to 0.4% (P =.019), and overall VASC increased slightly from 1.2% to 1.4% (P =.047).

From 2013 to 2017, the secondary vascular access site use among both transradial and transfemoral cases increased, which was steeper among transfemoral cases (2.9%-3.6% vs 5.6%-12.9%, respectively). Over the study period, the use of a secondary access site was associated with a significantly higher rate of VASC (odds ratio 5.82; 95% CI, 5.26-6.43). Crossover was more frequent in patients in the transfemoral PCI cohort, with 3.09% (n=3039) of these cases having an initial failed radial access attempt.

This study was limited by its retrospective and observational design, which lends itself to inherent biases. There may be unmeasured confounders, despite researchers’ attempts to account for possible confounders, including patient and procedural characteristics. Vascular access-site complications were clinically defined, and no systematic surveillance by imaging was performed. There was no information regarding sheath size. Bleeding events may have been underestimated because postprocedural hemoglobin was obtained per institutional practice and was not standardized. Data on mortality and stroke were not included as outcomes in this study. Finally, the sample may not represent the wider populations of patients undergoing PCI because it was drawn from a regional database with a strong culture of collaborative quality improvement.

In real-world practice, the stable rates of VASC despite the increasing frequency of transcranial PCI appear to be the result of a combination of factors, including increased use of higher-risk procedures that require a second vascular access site, increased transfemoral vascular complications, and the more comorbid population of patients undergoing PCI. To reduce vascular complications associated with transfemoral PCI and PCI requiring a secondary vascular access site, further research is needed to investigate the use of procedural techniques and training programs.

Reference

Kopin D, Seth M, Sukul D, et al. Primary and secondary vascular access site complications associated with percutaneous coronary intervention: insights from BMC2 [published online August 28, 2019]. JACC Cardiovasc Interv. doi: 10.1016/j.jcin.2019.05.051