1
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Senguttuvan NB, Reddy PMK, Shankar P, Abdulkader RS, Yallanki HP, Kumar A, Majmundar M, Ramalingam V, Rajendran R, Bhoopalan K, Kaliyamoorthy D, T. R. M, Kalra A, Jayaraj R, Ramakrishnan S, Daggubati R, Thanikachalam S, Seth A, Bahl VK. Trans-radial approach versus trans-femoral approach in patients with acute coronary syndrome undergoing percutaneous coronary intervention: An updated meta-analysis of randomized controlled trials. PLoS One 2022; 17:e0266709. [PMID: 35483028 PMCID: PMC9050011 DOI: 10.1371/journal.pone.0266709] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/25/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Trans-radial approach (TRA) is recommended over trans-femoral approach (TFA) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). We intended to study the effect of access on all-cause mortality. Methods and results We searched PubMed and EMBASE for randomized studies on patients with ACS undergoing PCI. The primary outcome was all-cause mortality at 30-days. The secondary outcomes included in-hospital mortality, major adverse cardiac or cerebrovascular event (MACE) as defined by the study, net adverse clinical event (NACE), non-fatal myocardial infarction, non-fatal stroke, stent thrombosis, study-defined major bleeding, and minor bleeding, vascular complications, hematoma, pseudoaneurysm, non-access site bleeding, need for transfusion, access site cross-over, contrast volume, procedure duration, and hospital stay duration. We studied 20,122 ACS patients, including 10,037 and 10,085 patients undergoing trans-radial and trans-femoral approaches, respectively. We found mortality benefit in patients with ACS for the trans-radial approach [(1.7% vs. 2.3%; RR: 0.75; 95% CI: 0.62–0.91; P = 0.004; I2 = 0%). Out of 10,465 patients with STEMI, 5,189 patients had TRA and 5,276 had TFA procedures. A similar benefit was observed in patients with STEMI alone [(2.3% vs. 3.3%; RR: 0.71; 95% CI: 0.56–0.90; P = 0.004; I2 = 0%). We observed reduced MACE, NACE, major bleeding, vascular complications, and pseudoaneurysms. No difference in re-infarction, stroke, and serious bleeding requiring blood transfusions were noted. We noticed a small decrease in contrast volume(ml) {mean difference (95% CI): −4.6 [−8.5 to −0.7]}, small but significantly increase in procedural time {mean difference (95% CI) 1.2 [0.1 to 2.3]}and fluoroscopy time {mean difference (95% CI) 0.8 [0.3 to1.4] min} in the trans-radial group. Conclusion TRA has significantly reduced 30-day all-cause mortality among patients undergoing PCI for ACS. TRA should be the preferred vascular access in patients with ACS.
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Affiliation(s)
- Nagendra Boopathy Senguttuvan
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, Tamil Nadu, India
- Adjunct Faculty, Department of Engineering and design, Indian Institute of Technology-Madras, Chennai, India
- * E-mail:
| | - Pothireddy M. K. Reddy
- Department of Medicine, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, Tamil Nadu, India
| | - PunatiHari Shankar
- Department of Medicine, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, Tamil Nadu, India
| | | | - Hanumath Prasad Yallanki
- Department of Medicine, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, Tamil Nadu, India
| | - Ashish Kumar
- Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, Ohio
| | - Monil Majmundar
- Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, Ohio
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital, New York, New York, United States of America
| | - Vadivelu Ramalingam
- Department of Cardiology, Velammal Medical College and Hospital, Madurai, India
| | | | | | | | - Muralidharan T. R.
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, Tamil Nadu, India
| | - Ankur Kalra
- Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Ramesh Daggubati
- Department of Cardiovascular Medicine, WVU Heart and Vascular Institute, Morgantown, India
| | - Sadagopan Thanikachalam
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, Tamil Nadu, India
| | - Ashok Seth
- Department of Cardiology, Fortis Escorts Heart Institute, New Delhi, India
| | - Vinay Kumar Bahl
- Department of Cardiovascular Medicine, WVU Heart and Vascular Institute, Morgantown, India
- Department of Cardiology, Max- Super-speciality Hospitals, New Delhi, India
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Malik AH, Yandrapalli S, Shetty SS, Zaid S, Athar A, Aronow WS, Timmermans RJ, Ahmad H, Cooper HA, Naidu SS, Panza JA. Radial vs. Femoral Access for Percutaneous Coronary Artery Intervention in Patients With ST-Elevation Myocardial Infarction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 28:57-64. [PMID: 32981856 DOI: 10.1016/j.carrev.2020.06.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/27/2020] [Accepted: 06/15/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND We aimed to compare the safety and efficacy of transradial vs transfemoral access for coronary angiography and intervention in patients presenting with ST-segment elevation myocardial infarction (STEMI) without cardiogenic shock. METHODS PubMed, Embase and Cochrane Central were searched for randomized controlled trials (RCTs) comparing outcomes of STEMI patients who underwent transradial angiography (TRA) compared to transfemoral angiography (TFA). Our outcomes of interest were major adverse cardiac events (MACE), all-cause mortality, severe bleeding, access site bleeding, myocardial infarction, stroke, and major vascular complications. Summary statistics are reported as odds ratios (OR) with 95% confidence intervals (CI). RESULTS In a pooled analysis of 17 RCTs with 12,118 randomized patients, the use of transradial compared to transfemoral approach in STEMI patients without cardiogenic shock was associated with a significant reduction in MACE [OR 0.85 (95% CI 0.73-0.99; p = 0.04; NNT = 111; I2 = 0%)] and all-cause mortality [OR 0.71 (95% CI 0.57-0.88; p < 0.01; NNT = 111; I2 = 0%)]. Severe bleeding [OR 0.57 (95% CI 0.44-0.74; p < 0.01; NNT = 77; I2 = 0%)], access-site bleeding [OR 0.39 (95% CI 0.26-0.59; p < 0.01; NNT = 67; I2 = 24%)], and major vascular complications [OR of 0.31 (95% CI 0.17-0.55; p < 0.01; NNT = 125; I2 = 0%)] were lower in TRA compared to TFA. There was no difference in stroke (0.6% vs 0.5%) or recurrent myocardial infarction (2.01% vs 2.02%) between the two approaches. CONCLUSIONS For coronary intervention in STEMI patients without cardiogenic shock, there is a clear mortality benefit with the TRA over TFA. Further studies are needed to see if this mortality benefit persists over the long-term.
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Affiliation(s)
- Aaqib H Malik
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA.
| | - Srikanth Yandrapalli
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Suchith S Shetty
- Division of Cardiology, Department of Internal Medicine, University of Iowa Health Care, Carver College of Medicine, Iowa City, USA
| | - Syed Zaid
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Ammar Athar
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Robert J Timmermans
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Hasan Ahmad
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Howard A Cooper
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Julio A Panza
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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3
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Glycoprotein IIb/IIIa Inhibitors May Modulate the Clinical Benefit of Radial Access as Compared to Femoral Access in Primary Percutaneous Coronary Intervention: A Meta-Regression and Meta-Analysis of Randomized Trials. J Interv Cardiol 2021; 2021:9917407. [PMID: 34220370 PMCID: PMC8221896 DOI: 10.1155/2021/9917407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/04/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Several randomized controlled trials (RCTs) consistently reported better clinical outcomes with radial as compared to femoral access for primary percutaneous coronary intervention (PCI). Nevertheless, heterogeneous use of potent antiplatelet drugs, such as Gp IIb/IIIa inhibitors (GPI), across different studies could have biased the results in favor of radial access. We performed an updated meta-analysis and meta-regression of RCTs in order to appraise whether the use of GPI had an impact on pooled estimates of clinical outcomes according to vascular access. Methods We computed pooled estimates by the random-effects model for the following outcomes: mortality, major adverse cardiovascular events (death, myocardial infarction, stroke, and target vessel revascularization), and major bleedings. Additionally, we performed meta-regression analysis to investigate the impact of GPI use on pooled estimates of clinical outcomes. Results We analyzed 14 randomized controlled trials and 11090 patients who were treated by radial (5497) and femoral access (5593), respectively. Radial access was associated with better outcomes for mortality (risk difference 0.01 (0.00, 0.01), p=0.03), MACE (risk difference 0.01 (0.00, 0.02), p=0.003), and major bleedings (risk difference 0.01 (0.00, 0.02), p=0.02). At meta-regression, we observed a significant correlation of mortality with both GPI use (p=0.011) and year of publication (p=0.0073), whereas no correlation was observed with major bleedings. Conclusions In this meta-analysis, the use of radial access for primary PCI was associated with better clinical outcomes as compared to femoral access. However, the effect size on mortality was modulated by GPI rate, with greater benefit of radial access in studies with larger use of these drugs.
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4
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Changal K, Syed MA, Atari E, Nazir S, Saleem S, Gul S, Salman FNU, Inayat A, Eltahawy E. Transradial versus transfemoral access for cardiac catheterization: a nationwide pilot study of training preferences and expertise in The United States. BMC Cardiovasc Disord 2021; 21:250. [PMID: 34020605 PMCID: PMC8139069 DOI: 10.1186/s12872-021-02068-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 05/17/2021] [Indexed: 11/10/2022] Open
Abstract
Background The objective was to assess current training preferences, expertise, and comfort with transfemoral access (TFA) and transradial access (TRA) amongst cardiovascular training fellows and teaching faculty in theUnited States. As TRA continues to dominate the field of interventional cardiology, there is a concern that trainees may become less proficient with the femoral approach. Methods A detailed questionnaire was sent out to academic General Cardiovascular and Interventional Cardiology training programs in the United States. Responses were sought from fellows-in-training and faculty regarding preferences and practice of TFA and TRA. Answers were analyzed for significant differences between trainees and trainers. Results A total of 125 respondents (75 fellows-in-training and 50 faculty) completed and returned the survey. The average grade of comfort for TFA, on a scale of 0 to 10 (10 being most comfortable), was reported to be 6 by fellows-in-training and 10 by teaching faculty (p<0.001). TRA was the first preference in 95% of the fellows-in-training compared to 69% of teaching faculty (p 0.001). While 62% of fellows believed that they would receive the same level of training as their trainers by the time they graduate, only 35% of their trainers believed so (p 0.004). Conclusion The shift from TFA to radial first has resulted in significant concern among cardiovascular fellows-in training and the faculty regarding training in TFA. Cardiovascular training programs must be cognizant of this issue and should devise methods to assure optimal training of fellows in gaining TFA and managing femoral access-related complications.
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Affiliation(s)
- Khalid Changal
- Department of Cardiovascular Medicine, University of Toledo, Toledo, OH, USA.
| | | | - Ealla Atari
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA
| | - Salik Nazir
- Department of Cardiovascular Medicine, University of Toledo, Toledo, OH, USA
| | - Sameer Saleem
- Department of Cardiovascular Medicine, University of Kentucky, Bowling Green, USA
| | - Sajjad Gul
- Internal Medicine, St. Francis Medical Center, University of Illinois at Peoria, Peoria, USA
| | - F N U Salman
- Internal Medicine, Mercy St. Vincent Medical Center, Toledo, OH, USA
| | - Asad Inayat
- Department of Medicine, Khyber Teaching Hospital, Peshawar, Pakistan
| | - Ehab Eltahawy
- Professor and Program Director of Cardiovascular Medicine and Interventional Cardiology, University of Toledo, 3000 Arlington Ave., MS 1118, Toledo, 43614, OH, USA.
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5
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Bajraktari G, Rexhaj Z, Elezi S, Zhubi-Bakija F, Bajraktari A, Bytyçi I, Batalli A, Henein MY. Radial Access for Coronary Angiography Carries Fewer Complications Compared with Femoral Access: A Meta-Analysis of Randomized Controlled Trials. J Clin Med 2021; 10:jcm10102163. [PMID: 34067672 PMCID: PMC8156941 DOI: 10.3390/jcm10102163] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND AIM In patients undergoing diagnostic coronary angiography (CA) and percutaneous coronary interventions (PCI), the benefits associated with radial access compared with the femoral access approach remain controversial. The aim of this meta-analysis was to compare the short-term evidence-based clinical outcome of the two approaches. METHODS The PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) comparing radial versus femoral access for CA and PCI. We identified 34 RCTs with 29,352 patients who underwent CA and/or PCI and compared 14,819 patients randomized for radial access with 14,533 who underwent procedures using femoral access. The follow-up period for clinical outcome was 30 days in all studies. Data were pooled by meta-analysis using a fixed-effect or a random-effect model, as appropriate. Risk ratios (RRs) were used for efficacy and safety outcomes. RESULTS Compared with femoral access, the radial access was associated with significantly lower risk for all-cause mortality (RR: 0.74; 95% confidence interval (CI): 0.61 to 0.88; p = 0.001), major bleeding (RR: 0.53; 95% CI:0.43 to 0.65; p ˂ 0.00001), major adverse cardiovascular events (MACE)(RR: 0.82; 95% CI: 0.74 to 0.91; p = 0.0002), and major vascular complications (RR: 0.37; 95% CI: 0.29 to 0.48; p ˂ 0.00001). These results were consistent irrespective of the clinical presentation of ACS or STEMI. CONCLUSIONS Radial access in patients undergoing CA with or without PCI is associated with lower mortality, MACE, major bleeding and vascular complications, irrespective of clinical presentation, ACS or STEMI, compared with femoral access.
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Affiliation(s)
- Gani Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, 90187 Umeå, Sweden; (A.B.); (I.B.); (M.Y.H.)
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
- Medical Faculty, University of Prishtina “Hasan Prishtina”, 10000 Prishtina, Kosovo
- UBT College, 10000 Prishtina, Kosovo
- Correspondence:
| | - Zarife Rexhaj
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
| | - Shpend Elezi
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
- Medical Faculty, University of Prishtina “Hasan Prishtina”, 10000 Prishtina, Kosovo
| | - Fjolla Zhubi-Bakija
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
| | - Artan Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, 90187 Umeå, Sweden; (A.B.); (I.B.); (M.Y.H.)
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
| | - Ibadete Bytyçi
- Department of Public Health and Clinical Medicine, Umeå University, 90187 Umeå, Sweden; (A.B.); (I.B.); (M.Y.H.)
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
| | - Arlind Batalli
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
- Medical Faculty, University of Prishtina “Hasan Prishtina”, 10000 Prishtina, Kosovo
| | - Michael Y. Henein
- Department of Public Health and Clinical Medicine, Umeå University, 90187 Umeå, Sweden; (A.B.); (I.B.); (M.Y.H.)
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6
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Di Santo P, Simard T, Wells GA, Jung RG, Ramirez FD, Boland P, Marbach JA, Parlow S, Kyeremanteng K, Coyle D, Fergusson D, Russo JJ, Chong AY, Froeschl M, So DY, Dick A, Glover C, Labinaz M, Hibbert B, Le May M. Transradial Versus Transfemoral Access for Percutaneous Coronary Intervention in ST-Segment-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis. Circ Cardiovasc Interv 2021; 14:e009994. [PMID: 33685220 DOI: 10.1161/circinterventions.120.009994] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Pietro Di Santo
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,School of Epidemiology and Public Health (P.D.S., D.C., D.F., G.A.W.), University of Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Trevor Simard
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada.,Department of Cellular and Molecular Medicine (T.S., R.G.J., B.H.), University of Ottawa, Canada
| | - George A Wells
- Cardiovascular Research Methods Centre (G.A.W.), University of Ottawa Heart Institute, Ottawa, Canada.,School of Epidemiology and Public Health (P.D.S., D.C., D.F., G.A.W.), University of Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Richard G Jung
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada.,Department of Cellular and Molecular Medicine (T.S., R.G.J., B.H.), University of Ottawa, Canada
| | - F Daniel Ramirez
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Hôpital Cardiologique du Haut Lévêque, CHU Bordeaux, France (F.D.R.).,LIRYC (L'Institut de Rythmologie et Modélisation Cardiaque), Bordeaux-Pessac, France (F.D.R.)
| | - Paul Boland
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Jeffrey A Marbach
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Simon Parlow
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Kwadwo Kyeremanteng
- Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada.,Division of Critical Care, Department of Medicine (K.K.), University of Ottawa, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health (P.D.S., D.C., D.F., G.A.W.), University of Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Dean Fergusson
- School of Epidemiology and Public Health (P.D.S., D.C., D.F., G.A.W.), University of Ottawa, Canada
| | - Juan J Russo
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Aun-Yeong Chong
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Michael Froeschl
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Derek Y So
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Alexander Dick
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Christopher Glover
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Marino Labinaz
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
| | - Benjamin Hibbert
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada.,Department of Cellular and Molecular Medicine (T.S., R.G.J., B.H.), University of Ottawa, Canada
| | - Michel Le May
- CAPITAL Research Group, Division of Cardiology, Department of Medicine (P.D.S., T.S., R.G.J., F.D.R., P.B., J.A.M., S.P., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa Heart Institute, Ottawa, Canada.,Faculty of Medicine (P.D.S., T.S., G.A.W., R.G.J., P.B., J.A.M., S.P., K.K., D.C., J.J.R., A.-Y.C., M.F., D.Y.S., A.D., C.G., M.L., B.H., M.L.M.), University of Ottawa, Canada
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7
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Jhand A, Atti V, Gwon Y, Dhawan R, Turagam MK, Mamas MA, Brilakis ES, Kumar A, Katta N, Chatzizisis Y, Parikh M, Abbott JD, Kirtane AJ, Bhatt DL, Velagapudi P. Meta-Analysis of Transradial vs Transfemoral Access for Percutaneous Coronary Intervention in Patients With ST Elevation Myocardial Infarction. Am J Cardiol 2021; 141:23-30. [PMID: 33220324 DOI: 10.1016/j.amjcard.2020.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 01/07/2023]
Abstract
Transradial access (TRA) has emerged as an alternative to transfemoral access (TFA) for percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) patients. However, the rate of TRA adoption has been much slower in the acute coronary syndrome (ACS) patient population. This meta-analysis was conducted to assess clinical outcomes of TRA compared with TFA in STEMI patients undergoing PCI. A manual search of PubMed, EMBASE, Cochrane library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and recent major scientific conference sessions from inception to October 15th, 2019 was performed. Primary outcomes in our analysis were all-cause mortality and trial-defined major bleeding. Secondary outcomes included vascular complications, myocardial infarction, stroke, procedure, and fluoroscopy time. 17 randomized controlled trials (RCTs) (N = 12,018) met inclusion criteria. TRA was associated with lower all-cause mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.57 to 0.88), major bleeding (RR: 0.59, 95%CI: 0.45 to 0.77), and vascular complications (RR: 0.42, 95%CI: 0.32 to 0.56) compared with TFA. There was no difference in the incidence of myocardial infarction (MI), stroke, or procedure duration between the 2 groups. The difference in all-cause mortality between TRA and TFA was statistically nonsignificant when major bleeding was held constant. In conclusion, TRA was associated with lower risk of all-cause mortality, major bleeding, and vascular complications compared with TFA in STEMI patients undergoing PCI.
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Affiliation(s)
| | | | - Yeongjin Gwon
- University of Nebraska Medical Center, Omaha, Nebraska
| | - Rahul Dhawan
- University of Nebraska Medical Center, Omaha, Nebraska
| | - Mohit K Turagam
- The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, UK
| | | | | | - Natraj Katta
- University of Nebraska Medical Center, Omaha, Nebraska
| | | | | | | | - Ajay J Kirtane
- Columbia University Irving Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
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8
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Chiarito M, Cao D, Nicolas J, Roumeliotis A, Power D, Chandiramani R, Sartori S, Camaj A, Goel R, Claessen BE, Stefanini GG, Mehran R, Dangas G. Radial versus femoral access for coronary interventions: An updated systematic review and meta‐analysis of randomized trials. Catheter Cardiovasc Interv 2021; 97:1387-1396. [DOI: 10.1002/ccd.29486] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/06/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Mauro Chiarito
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
- Cardio Center Humanitas Clinical and Research Center IRCCS Milan Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
| | - Anastasios Roumeliotis
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
| | - David Power
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
| | - Rishi Chandiramani
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
| | - Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
| | - Ridhima Goel
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
| | - Bimmer E. Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
| | | | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York New York
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9
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Osman M, Saleem M, Osman K, Kheiri B, Regner S, Radaideh Q, Moreland JA, Rao SV, Kapadia S. Radial versus femoral access for percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction: Trial sequential analysis. Am Heart J 2020; 224:98-104. [PMID: 32361279 DOI: 10.1016/j.ahj.2020.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 03/14/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Randomized controlled trials (RCTs) have yielded conflicting results about the impact of transradial access (TRA) versus transfemoral access (TFA) in patients with ST-segment elevation myocardial infarction (STEMI). METHODS We performed a trial sequential analysis (TSA) of RCTs comparing TRA and TFA in patients with STEMI. The outcomes of interest were 30-day mortality, major bleeding, major adverse cardiovascular events (MACE), myocardial infarction (MI), stroke, and access site complications. RESULTS A total of 17 studies with 11,992 patients were included in the current TSA. The TRA group had lower 30-day mortality (risk ratio [RR] 0.72, 95% CI 0.58-0.90, P = .003), major bleeding (RR 0.62, 95% CI 0.49-0.79, P = .0001), MACE (RR 0.74, 95% CI 0.58-0.93, P = .01), and access site complications (RR 0.37, 95% CI 0.28-0.48, P < .00001). There was no difference in MI and stroke between the 2groups. Applying TSA boundaries, the z-curve for 30-day mortality, major bleeding, MACE and access site complications crossed the conventional and the TSA boundaries, indicating firm evidence for better outcomes in the TRA group. For MI and stroke, the z-curve failed to cross the conventional and the TSA boundaries for both outcomes, indicating lack of signals of benefit or harm. CONCLUSIONS In the current TSA, the available data from RCTs support improved 30-day mortality, major bleeding, MACE and access site complication rates in STEMI patients treated by PCI through the radial access.
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Affiliation(s)
- Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA.
| | - Maryam Saleem
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Khansa Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Babikir Kheiri
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Sean Regner
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Qais Radaideh
- Division of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Jason A Moreland
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Sunil V Rao
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - Samir Kapadia
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, OH, USA
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10
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Mason PJ, Shah B, Tamis-Holland JE, Bittl JA, Cohen MG, Safirstein J, Drachman DE, Valle JA, Rhodes D, Gilchrist IC. 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 2019; 11:e000035. [PMID: 30354598 DOI: 10.1161/hcv.0000000000000035] [Citation(s) in RCA: 304] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Transradial artery access for percutaneous coronary intervention is associated with lower bleeding and vascular complications than transfemoral artery access, especially in patients with acute coronary syndromes. A growing body of evidence supports adoption of transradial artery access to improve acute coronary syndrome-related outcomes, to improve healthcare quality, and to reduce cost. The purpose of this scientific statement is to propose and support a "radial-first" strategy in the United States for patients with acute coronary syndromes. This document also provides an update to previously published statements on transradial artery access technique and best practices, particularly as they relate to the management of patients with acute coronary syndromes.
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11
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Meertens MM, Ng E, Loh SEK, Samuel M, Mees BME, Choong AMTL. Transradial Approach for Aortoiliac and Femoropopliteal Interventions: A Systematic Review and Meta-analysis. J Endovasc Ther 2018; 25:599-607. [PMID: 30086665 PMCID: PMC6136071 DOI: 10.1177/1526602818792854] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE To present a systematic review and meta-analysis comparing the transradial approach for aortoiliac and femoropopliteal interventions to the traditional transfemoral access. METHODS A search of the public domain databases MEDLINE, SCOPUS, Web of Science, and Cochrane Library Databases was performed to identify studies related to the use of the transradial approach for infra-aortic procedures. Meta-analysis was used to compare the transradial to the transfemoral route in terms of procedure success, complications, procedure parameters, and hospital length of stay. Results are presented as the odds ratio (OR) and 95% confidence interval (CI). RESULTS Nineteen studies containing 638 patients with transradial access for lower limb interventions were selected. Lesions were treated from the aortic bifurcation down to the popliteal artery. The mean technical success rate was 90.9%, conversion to a transfemoral approach was necessary in 9.9%, and complications were reported in 1.9%. The meta-analysis included 4 comparative studies involving 114 transradial and 208 transfemoral procedures. There was no significant advantage of either approach in terms of procedure success (OR 5.0, 95% CI 0.49 to 50.83, p=0.17), but the risk of developing a complication was significantly lower (OR 0.25, 95% CI 0.07 to 0.86, p=0.03) with the transradial approach. CONCLUSION Transradial access for lower limb endovascular interventions can be performed with comparable technical success and a lower overall complication profile compared to transfemoral access.
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Affiliation(s)
- Max M. Meertens
- SingVaSC, Singapore Vascular Surgical
Collaborative, Singapore
- Department of Vascular Surgery,
Maastricht University Medical Center, Maastricht, the Netherlands
- European Vascular Center
Aachen-Maastricht, Aachen, Germany
| | - Eugene Ng
- SingVaSC, Singapore Vascular Surgical
Collaborative, Singapore
- Department of Vascular Surgery, Westmead
Hospital, Westmead, NSW, Australia
| | - Stanley E. K. Loh
- SingVaSC, Singapore Vascular Surgical
Collaborative, Singapore
- Department of Diagnostic Imaging,
National University Hospital, Singapore
| | - Miny Samuel
- SingVaSC, Singapore Vascular Surgical
Collaborative, Singapore
- Systematic Review Unit, Yong Loo Lin
School of Medicine, National University of Singapore
| | - Barend M. E. Mees
- Department of Vascular Surgery,
Maastricht University Medical Center, Maastricht, the Netherlands
- European Vascular Center
Aachen-Maastricht, Aachen, Germany
| | - Andrew M. T. L. Choong
- SingVaSC, Singapore Vascular Surgical
Collaborative, Singapore
- Division of Vascular Surgery, National
University Heart Centre, Singapore
- Department of Surgery, Yong Loo Lin
School of Medicine, National University of Singapore
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12
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Kolkailah AA, Alreshq RS, Muhammed AM, Zahran ME, Anas El‐Wegoud M, Nabhan AF. Transradial versus transfemoral approach for diagnostic coronary angiography and percutaneous coronary intervention in people with coronary artery disease. Cochrane Database Syst Rev 2018; 4:CD012318. [PMID: 29665617 PMCID: PMC6494633 DOI: 10.1002/14651858.cd012318.pub2] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the major cause of mortality worldwide. Coronary artery disease (CAD) contributes to half of mortalities caused by CVD. The mainstay of management of CAD is medical therapy and revascularisation. Revascularisation can be achieved via coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Peripheral arteries, such as the femoral or radial artery, provide the access to the coronary arteries to perform diagnostic or therapeutic (or both) procedures. OBJECTIVES To assess the benefits and harms of the transradial compared to the transfemoral approach in people with CAD undergoing diagnostic coronary angiography (CA) or PCI (or both). SEARCH METHODS We searched the following databases for randomised controlled trials on 10 October 2017: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Web of Science Core Collection. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform in August 2017. There were no language restrictions. Reference lists were also checked and we contacted authors of included studies for further information. SELECTION CRITERIA We included randomised controlled trials that compared transradial and transfemoral approaches in adults (18 years of age or older) undergoing diagnostic CA or PCI (or both) for CAD. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. At least two authors independently screened trials, extracted data, and assessed the risk of bias in the included studies. We contacted trial authors for missing information. We used risk ratio (RR) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) for continuous data, with their 95% confidence intervals (CIs). All analyses were checked by another author. MAIN RESULTS We identified 31 studies (44 reports) including 27,071 participants and two ongoing studies. The risk of bias in the studies was low or unclear for several domains. Compared to the transfemoral approach, the transradial approach reduced short-term net adverse clinical events (NACE) (i.e. assessed during hospitalisation and up to 30 days of follow-up) (RR 0.76, 95% CI 0.61 to 0.94; 17,133 participants; 4 studies; moderate quality evidence), cardiac death (RR 0.69, 95% CI 0.54 to 0.88; 11,170 participants; 11 studies; moderate quality evidence). However, short-term myocardial infarction was similar between both groups (RR 0.91, 95% CI 0.81 to 1.02; 19,430 participants; 11 studies; high quality evidence). The transradial approach had a lower procedural success rate (RR 0.97, 95% CI 0.96 to 0.98; 25,920 participants; 28 studies; moderate quality evidence), but was associated with a lower risk of all-cause mortality (RR 0.77, 95% CI 0.62 to 0.95; 18,955 participants; 10 studies; high quality evidence), bleeding (RR 0.54, 95% CI 0.40 to 0.74; 23,043 participants; 20 studies; low quality evidence), and access site complications (RR 0.36, 95% CI 0.22 to 0.59; 16,112 participants; 24 studies; low quality evidence). AUTHORS' CONCLUSIONS Transradial approach for diagnostic CA or PCI (or both) in CAD may reduce short-term NACE, cardiac death, all-cause mortality, bleeding, and access site complications. There is insufficient evidence regarding the long-term clinical outcomes (i.e. beyond 30 days of follow-up).
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Affiliation(s)
- Ahmed A Kolkailah
- John H. Stroger, Jr. Hospital of Cook CountyDepartment of MedicineChicagoILUSA
| | | | - Ahmed M Muhammed
- Faculty of Medicine, Ain Shams UniversityDepartment of CardiologyCairoEgypt
| | - Mohamed E Zahran
- Faculty of Medicine, Ain Shams UniversityDepartment of CardiologyCairoEgypt
| | - Marwah Anas El‐Wegoud
- Egyptian Center for Evidence Based Medicine (ECEBM)8 Masaken Hayet El Tadrees Ain Shams University, El Khalifa El Maamoun St.CairoEgypt11646
| | - Ashraf F Nabhan
- Ain Shams UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine16 Ali Fahmi Kamel StreetHeliopolisCairoEgypt11351
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13
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Heshmat H, haddad YE, Farouk M, Abdelmegeed M. Radial Access in Primary PCI for Acute Myocardial Infarction. Interv Cardiol 2017. [DOI: 10.5772/intechopen.69131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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14
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Brener MI, Bush A, Miller JM, Hasan RK. Influence of radial versus femoral access site on coronary angiography and intervention outcomes: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2017; 90:1093-1104. [DOI: 10.1002/ccd.27043] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 02/25/2017] [Indexed: 12/21/2022]
Affiliation(s)
| | - Aaron Bush
- Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Julie M. Miller
- Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Rani K. Hasan
- Johns Hopkins University School of Medicine; Baltimore Maryland
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15
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Ferrante G, Rao SV, Jüni P, Da Costa BR, Reimers B, Condorelli G, Anzuini A, Jolly SS, Bertrand OF, Krucoff MW, Windecker S, Valgimigli M. Radial Versus 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; 9:1419-34. [PMID: 27372195 DOI: 10.1016/j.jcin.2016.04.014] [Citation(s) in RCA: 332] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/11/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to provide a quantitative appraisal of the effects on clinical outcomes of radial access for coronary interventions in patients with coronary artery disease (CAD). BACKGROUND Randomized trials investigating radial versus femoral access for percutaneous coronary interventions have provided conflicting evidence. No comprehensive quantitative appraisal of the risks and benefits of each approach is available across the whole spectrum of patients with stable or unstable CAD. METHODS The PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for randomized trials comparing radial versus femoral access for coronary interventions. Data were pooled by meta-analysis using a fixed-effects or a random-effects model, as appropriate. Pre-specified subgroup analyses according to clinical presentation, in terms of stable CAD, non-ST-segment elevation acute coronary syndromes, or ST-segment elevation myocardial infarction were performed. RESULTS Twenty-four studies enrolling 22,843 participants were included. Compared with femoral access, radial access was associated with a significantly lower risk for all-cause mortality (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.59 to 0.87; p = 0.001, number needed to treat to benefit [NNTB] = 160), major adverse cardiovascular events (OR: 0.84; 95% CI: 0.75 to 0.94; p = 0.002; NNTB = 99), major bleeding (OR: 0.53; 95% CI: 0.42 to 0.65; p < 0.001; NNTB = 103), and major vascular complications (OR: 0.23; 95% CI: 0.16 to 0.35; p < 0.001; NNTB = 117). The rates of myocardial infarction or stroke were similar in the 2 groups. Effects of radial access were consistent across the whole spectrum of patients with CAD for all appraised endpoints. CONCLUSIONS Compared with femoral access, radial access reduces mortality and MACE and improves safety, with reductions in major bleeding and vascular complications across the whole spectrum of patients with CAD.
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Affiliation(s)
- Giuseppe Ferrante
- Department of Cardiovascular Medicine, Humanitas Research Hospital, Humanitas Clinical and Research Center, Rozzano, Italy.
| | - Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina
| | - Peter Jüni
- Applied Health Research Centre The HUB, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bruno R Da Costa
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Bernhard Reimers
- Department of Cardiovascular Medicine, Humanitas Research Hospital, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Gianluigi Condorelli
- Department of Cardiovascular Medicine, Humanitas Research Hospital, Humanitas Clinical and Research Center, Rozzano, Italy; Humanitas University, Rozzano, Italy
| | - Angelo Anzuini
- Department of Interventional Cardiology, Humanitas Mater Domini, Castellanza, Italy
| | - Sanjit S Jolly
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Olivier F Bertrand
- Interventional Cardiology, Quebec Heart-Lung Institute, Quebec City, Quebec, Canada
| | | | - Stephan Windecker
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland.
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16
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Singh S, Singh M, Grewal N, Khosla S. Transradial vs Transfemoral Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction: A Systemic Review and Meta-analysis. Can J Cardiol 2016; 32:777-90. [PMID: 27233893 DOI: 10.1016/j.cjca.2015.08.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/01/2015] [Accepted: 08/19/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The objective of this meta-analysis to evaluate safety and efficacy of transradial vs the transfemoral approach for primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients. METHODS Randomized controlled trials that compared the transfemoral vs the transradial approach in STEMI patients who underwent PCI were searched in PubMed, Embase, CENTRAL, Cumulative Index to Nursing and Allied Health Literature, and clinicaltrials.gov. Random effect models were used to pool effect sizes. RESULTS Sixteen trials, comprising data from 9726 patients, were included in the meta-analysis. All-cause mortality (risk ratio [RR], 0.68; 95% confidence interval [CI], 0.54-0.85; relative risk reduction [RRR], 32.8%; I(2) = 0), major bleeding (RR 0.56; 95% CI, 0.42-0.74; RRR, 48.1%; I(2) = 0), access site bleeding (RR, 0.38; 95% CI, 0.29-0.50; RRR, 63.9%; I(2) = 0), major adverse cardiovascular events (RR, 0.80; 95% CI, 0.68-0.94; RRR, 19.3%; I(2) = 0), and length of hospital stay (standardized mean difference, -0.38 days; 95% CI, -0.46 to -0.31 days) were significantly lower with the transradial compared with the transfemoral approach. The greatest reduction in major bleeding was found in the subgroup with trials recruiting only primary PCI participants compared with varying proportions of rescue PCIs. Glycoprotein IIb/IIIa inhibitor use and cross-over rates did not have a significant association with outcome measures in the subgroup analysis. Incidence of stroke was numerically greater with the transradial approach but did not achieve statistical significance (RR, 1.22; 95% CI, 0.56-2.66; I(2) = 0). Overall statistical heterogeneity (I(2)) was very low except for length of hospital stay. CONCLUSIONS The transradial approach for PCI in STEMI patients significantly reduced all-cause mortality, major and access site bleeding, major adverse cardiovascular events, and length of hospital stay. Difference in stroke incidence was not statistically significant with the transradial vs the transfemoral approach.
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Affiliation(s)
- Sukhchain Singh
- Department of Hospital Medicine at Ingalls Memorial Hospital, Harvey, Illinois, USA; Department of Cardiovascular Medicine at Mount Sinai Medical Center, Chicago, Illinois, USA.
| | - Mukesh Singh
- Chicago Medical School, North Chicago, Illinois, USA
| | - Navsheen Grewal
- Department of Cardiovascular Medicine at Mount Sinai Medical Center, Chicago, Illinois, USA; School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sandeep Khosla
- Department of Cardiovascular Medicine at Mount Sinai Medical Center, Chicago, Illinois, USA; Department of Cardiovascular Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
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Andò G, Capodanno D. Radial Access Reduces Mortality in Patients With Acute Coronary Syndromes. JACC Cardiovasc Interv 2016; 9:660-70. [DOI: 10.1016/j.jcin.2015.12.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 11/02/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
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Andò G, Capodanno D. Radial Versus Femoral Access in Invasively Managed Patients With Acute Coronary Syndrome: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:932-40. [PMID: 26551857 DOI: 10.7326/m15-1277] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Studies in patients with acute coronary syndrome (ACS) undergoing invasive management showed conflicting conclusions regarding the effect of access site on outcomes. PURPOSE To summarize evidence from recent, high-quality trials that compared clinical outcomes occurring with radial versus femoral access in invasively managed adults with ACS. DATA SOURCES English-language publications in MEDLINE, EMBASE, and Cochrane databases between January 1990 and August 2015. STUDY SELECTION Randomized trials of radial versus femoral access in invasively managed patients with ACS. DATA EXTRACTION Two investigators independently extracted the study data and rated the risk of bias. DATA SYNTHESIS Of 17 identified randomized trials, 4 were high-quality multicenter trials that involved a total of 17 133 patients. Pooled data from the 4 trials showed that radial access reduced death (relative risk [RR], 0.73 [95% CI, 0.59 to 0.90]; P = 0.003), major adverse cardiovascular events (RR, 0.86 [CI, 0.75 to 0.98]; P = 0.025), and major bleeding (RR, 0.57 [CI, 0.37 to 0.88]; P = 0.011). Radial procedures lasted slightly longer (standardized mean difference, 0.11 minutes) and had higher risk for access-site crossover (6.3% vs. 1.7%) than did femoral procedures. LIMITATION Heterogeneity in outcomes definitions and potential treatment modifiers across studies, including operator experience in radial procedures and concurrent anticoagulant regimens. CONCLUSION Compared with femoral access, radial access reduces mortality, major adverse cardiovascular events, and major bleeding in patients with ACS undergoing invasive management. PRIMARY FUNDING SOURCE None. (PROSPERO registration number: CRD42015022031).
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Affiliation(s)
- Giuseppe Andò
- From the University of Messina, Messina, and Ferrarotto Hospital, University of Catania, Catania, Italy
| | - Davide Capodanno
- From the University of Messina, Messina, and Ferrarotto Hospital, University of Catania, Catania, Italy
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Singh S, Singh M, Grewal N, Khosla S. The fluoroscopy time, door to balloon time, contrast volume use and prevalence of vascular access site failure with transradial versus transfemoral approach in ST segment elevation myocardial infarction: A systematic review & meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2015; 16:491-7. [DOI: 10.1016/j.carrev.2015.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/12/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022]
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Huff CM, Kapadia S, Rao SV. Mechanisms by which transradial approach may reduce mortality in ST-segment-elevation myocardial infarction. Circ Cardiovasc Interv 2015; 7:621-7. [PMID: 25139088 DOI: 10.1161/circinterventions.114.001627] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Christopher M Huff
- From the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH (C.M.H., S.K.); and The Duke Clinical Research Institute, Durham, NC (S.V.R.)
| | - Samir Kapadia
- From the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH (C.M.H., S.K.); and The Duke Clinical Research Institute, Durham, NC (S.V.R.).
| | - Sunil V Rao
- From the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH (C.M.H., S.K.); and The Duke Clinical Research Institute, Durham, NC (S.V.R.)
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Piccolo R, Galasso G, Capuano E, De Luca S, Esposito G, Trimarco B, Piscione F. Transradial versus transfemoral approach in patients undergoing percutaneous coronary intervention for acute coronary syndrome. A meta-analysis and trial sequential analysis of randomized controlled trials. PLoS One 2014; 9:e96127. [PMID: 24820096 PMCID: PMC4018335 DOI: 10.1371/journal.pone.0096127] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 04/03/2014] [Indexed: 11/19/2022] Open
Abstract
Background Transfemoral approach (TFA) remains the most common vascular access for percutaneous coronary intervention (PCI) in many countries. However, in the last years several randomized trials compared transradial approach (TRA) with TFA in patients with acute coronary syndrome (ACS), but only few studies were powered to estimate rare events. The aim of the current study was to clarify whether TRA is superior to TFA approach in patients with ACS undergoing percutaneous coronary intervention. A meta-analysis, meta-regression and trial sequential analysis of safety and efficacy of TRA in ACS setting was performed. Methods and Results Medline, the Cochrane Library, Scopus, scientific session abstracts and relevant websites were searched. Data concerning the study design, patient characteristics, risk of bias, and outcomes were extracted. The primary endpoint was death. Secondary endpoints were: major bleeding and vascular complications. Outcomes were assessed within 30 days. Eleven randomized trials involving 9,202 patients were included. Compared with TFA, TRA significantly reduced the risk of death (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.53–0.94; p = 0.016), but this finding was not confirmed in trial sequential analysis, indicating that sufficient evidence had not been yet reached. Furthermore, TRA compared with TFA reduced the risk of major bleeding (OR 0.60; 95% CI, 0.41–0.88; p = 0.008) and vascular complications (OR 0.35; 95% CI, 0.28–0.46; p<0.001); these findings were supported by trial sequential analyses. Conclusions In patients with ACS undergoing PCI, a lower risk of death was observed with TRA. Nevertheless, the association between mortality and TRA in ACS setting should be interpreted with caution because it is based on insufficient evidence. However, because of the clinical relevance associated with major bleeding and vascular complications reduction, TRA should be recommended as first-choice vascular access in patients with ACS undergoing cardiac catheterization.
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Affiliation(s)
- Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Gennaro Galasso
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
- * E-mail:
| | - Ernesto Capuano
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Stefania De Luca
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Bruno Trimarco
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Federico Piscione
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
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Radial versus femoral access for primary percutaneous interventions in ST-segment elevation myocardial infarction patients: a meta-analysis of randomized controlled trials. JACC Cardiovasc Interv 2014; 6:814-23. [PMID: 23968700 DOI: 10.1016/j.jcin.2013.04.010] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/11/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study sought to determine the safety and efficacy of radial access compared with femoral access for primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND Numerous randomized controlled trials, including several new studies, have compared outcomes of these approaches in the context of primary PCI for STEMI patients with inconclusive results. METHODS We performed a meta-analysis of randomized controlled trials to compare outcomes in STEMI patients undergoing radial versus femoral access for primary PCI. Primary outcomes were death and major bleeding evaluated at the longest available follow-up. Secondary outcomes included access site bleeding, stroke, and procedure time. Twelve studies (N = 5,055) were included. All trials were conducted in centers experienced with both approaches. RESULTS Compared with femoral approach, radial approach was associated with decreased risk of mortality (2.7% vs. 4.7%; odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.40 to 0.76; p < 0.001) and decreased risk of major bleeding (1.4% vs. 2.9%; OR: 0.51, 95% CI: 0.31 to 0.85; p = 0.01). Radial access was also associated with reduction in relative risk of access site bleeding (2.1% vs. 5.6%; OR: 0.35, 95% CI: 0.25 to 0.50; p < 0.001). Stroke risk was similar between both approaches (0.5% vs. 0.5%; OR: 1.07, 95% CI: 0.45 to 2.54; p = 0.87). The procedure time was slightly longer in the radial group than in the femoral group (mean difference: 1.52 min; 95% CI: 0.33 to 2.70, p = 0.01). CONCLUSIONS In STEMI patients undergoing primary PCI, the radial approach is associated with favorable outcomes and should be the preferred approach for experienced radial operators.
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De Luca G, Schaffer A, Wirianta J, Suryapranata H. Comprehensive meta-analysis of radial vs femoral approach in primary angioplasty for STEMI. Int J Cardiol 2013; 168:2070-81. [PMID: 23490083 DOI: 10.1016/j.ijcard.2013.01.161] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 11/04/2012] [Accepted: 01/13/2013] [Indexed: 11/25/2022]
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Appleton DL, Cooke RH, Rao SV, Jovin IS. Anticoagulation in transradial percutaneous coronary intervention. Catheter Cardiovasc Interv 2013; 83:237-42. [PMID: 23766092 DOI: 10.1002/ccd.25060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 05/07/2013] [Accepted: 06/01/2013] [Indexed: 01/01/2023]
Abstract
Transradial percutaneous coronary intervention (PCI) is associated with significant reductions in access site complications and major bleeding as compared with the transfemoral approach. Bivalirudin is now the most commonly used anticoagulant for transradial PCI in the United States, while weight adjusted unfractionated heparin remains the most common choice outside the United States. A growing number of reports suggest that transradial intervention may offer improved outcomes across a variety of clinical situations, including those at the highest risk of bleeding complications, such as those with acute myocardial infarction. The following review provides an overview of the studies evaluating anticoagulation in transradial PCI and a rationale for the combination of the transradial approach to coronary interventions with an optimal anticoagulant strategy to reduce both access site and nonaccess site-related bleeding.
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Affiliation(s)
- Darryn L Appleton
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
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Joyal D, Bertrand OF, Rinfret S, Shimony A, Eisenberg MJ. Meta-analysis of ten trials on the effectiveness of the radial versus the femoral approach in primary percutaneous coronary intervention. Am J Cardiol 2012; 109:813-8. [PMID: 22196787 DOI: 10.1016/j.amjcard.2011.11.007] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 11/03/2011] [Accepted: 11/03/2011] [Indexed: 01/19/2023]
Abstract
The radial approach in primary percutaneous coronary intervention (PCI) has been recently assessed in both randomized and observational studies. However, observational studies have several biases that favor the radial approach. We conducted a meta-analysis of randomized controlled trials to compare the clinical outcomes of radial and femoral approach in primary PCI for ST-segment elevation myocardial infarction. The outcomes of interest included death, major bleeding, vascular complications/hematoma, and procedure time. The data were pooled using random-effects models. Ten randomized controlled trials involving 3,347 patients met our inclusion criteria. The radial approach was associated with improved survival (odds ratio 0.53, 95% confidence interval 0.33-0.84) and reduced vascular complications/hematoma (odds ratio 0.35, 95% confidence interval 0.24-0.53). A nonsignificant trend was found toward reduced major bleeding with the radial approach (odds ratio 0.63, 95% confidence interval 0.35-1.12). The procedural time with the radial approach was longer by < 2 minutes (mean difference 1.76 minutes, 95% confidence interval 0.59-2.92). In conclusion, in patients undergoing primary PCI, the radial approach is associated with lower short-term mortality. When feasible, the radial approach should be the favored route in primary PCI.
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