Radial Access Superior to Femoral Access in Coronary Interventions

In patients who received coronary interventions, radial access was associated with a significantly lower risk of all-cause mortality compared with femoral access, according to a recent meta-analysis published in JACC: Cardiovascular Interventions.

Giuseppe Ferrante, MD, PhD, of the Department of Interventional Cardiology at Humanitas Clinical and Research Center in Milan, Italy, and colleagues, examined 24 studies with a total of 22 843 patients. Trials were included if they had a randomized design that compared radial vs femoral access for coronary intervention and if at least 50% of patients who underwent percutaneous coronary intervention also received coronary angiography.

As the researchers pointed out, radial access has been known to reduce access-site bleeding; however the learning curve to develop the necessary technical skills is steeper, compared with femoral access. “In the modern era, the superiority of radial access over femoral access may be attenuated due to smaller arterial sheaths and targeted anticoagulants that reduce bleeding risk,” they wrote.

All-cause mortality and major bleeding served as the 2 primary end points while the secondary end points were efficacy and safety outcomes, including myocardial infarction (MI), stroke, a composite of major adverse cardiovascular end points (MACE), and major vascular complications.

Radial access was associated with a significant lower risk of all-cause mortality compared with femoral access (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.58-0.87; P=.001; number needed to treat to benefit [NNTB]: 160). Risks of MACE (OR: 0.84; 95% CI: 0.75-0.94; P=.002; NNTB: 99), major bleeding (OR: 0.53; 95% CI: 0.42-0.65; P<.001; NNTB: 103), and major vascular complications (OR: 0.23; 95% CI: 0.16-0.34; P<.001; NNTB: 117) were also significantly lower with radial access. MI and stroke rates were similar between the 2 groups.

Specifically among patients with acute coronary syndrome (ACS), radial access was associated with fewer net adverse clinical end points (NACE; OR: 0.75; 95% CI: 0.61-0.91; P=.004; NNTB: 48). In analyses of subgroups of patients with stable coronary artery disease, the effect of the radial approach was consistent across all clinical end points in non-ST-segment elevation (NSTE) ACS and STEMI patients.

That being said, patients with stable coronary syndrome appeared to reap greater benefits from radial access on major bleeding compared to those with NSTE-ACS (P for interaction = .01) or STEMI (P for interaction = .06). Radial access also trended toward higher benefits on NACE in STEMI patients compared to NSTE-ACS patients (P for interaction = .06).

The authors noted, however, that “detection of significant heterogeneity and bias may reduce the strength of this analysis” and the “presence of significant heterogeneity for the end points of all-cause death and of MACE in the subgroup of NSTE-ACS patients” is a limitation of the study.

They also stated, “Although this meta-analysis provides evidence supporting the superiority of radial approach as compared to femoral approach, however, differences in absolute event rates between groups were small for several end points leading to a number needed to treat to benefit or harm above 100.”

Overall, radial access was associated with a 29% relative risk reduction in all-cause mortality and a 16% relative risk reduction in MACE, compared with femoral access. Major bleeding and major vascular complications were also reduced by 47% and 77%, respectively, and MI and stroke rates were similar between the 2 interventions.

“The mechanisms by which radial access is associated with reduced all-cause mortality compared to femoral access, specifically whether this involves a reduction in the risk of major bleeding, requires additional studies,” researchers concluded.

Reference

Ferrante G, Rao SV, Juni P, et al. Radial vs femoral access for coronary intervention across the entire spectrum of patients with coronary artery disease: a meta-analysis of randomized trials. JACC Cardiovasc Interv. 2016. doi:10.1016/j.jcin.2016.04.014.