In the JournalsPerspective

Despite low use, transradial access yields less bleeding than transfemoral access in rescue PCI

In patients undergoing rescue PCI after administration of fibrinolytic therapy, transradial access was used infrequently but was associated with lower rates of bleeding than transfemoral access, according to new registry data.

“We theorized that patients requiring rescue PCI would be at particularly high risk for bleeding complications,” Jay Giri, MD, MPH, assistant professor of medicine at Perelman School of Medicine and director of peripheral intervention, division of cardiovascular medicine, University of Pennsylvania, told Cardiology Today. “We wanted to understand whether the bleeding avoidance strategy of radial access was being adopted in this potentially high-risk group.”

Jay Giri, MD, MPH

Jay Giri

Giri and colleagues analyzed 9,494 patients from the National Cardiovascular Data Registry’s CathPCI Registry who underwent rescue PCI for STEMI between 2009 and 2013, stratified by access type. The outcomes of interest were in-hospital bleeding, vascular complications and mortality. They used a falsification endpoint of gastrointestinal bleeding as a way to assess for unmeasured confounding.

Transradial access and risk

The researchers found that transradial access was used in only 14.2% of cases, and compared with the transfemoral group, the transradial group was younger (P < .0001); more likely to be men (P = .0033); had higher BMI (P = .0004); was more likely to have a family history of CAD at age younger than 55 years (P = .03); had a higher glomerular filtration rate (P < .0001); and were less likely to have prior congestive HF (P = .02), cerebrovascular disease (P = .03), chronic lung disease (P = .03), hypertension (P = .03), dyslipidemia (P = .001) and CABG (P < .0001). They were also less likely to have had HF within the past 2 weeks (P = .007), cardiogenic shock (P < .0001) or cardiac arrest (P = .0007).

“We were surprised to see how few of these rescue PCI cases were approached with transradial access, given the increase in bleeding that one might expect when performing a procedure on a patient who recently received thrombolytic therapy,” Giri told Cardiology Today. “Even more interesting was the finding that among the group studied, patients at the highest risk for bleeding — those who would benefit most from transradial access — were least likely to receive that procedure. This counterintuitive finding is a demonstration of the ‘risk-treatment paradox,’ showing that doctors in these cases made treatment decisions based on what they are most comfortable with rather than what is best for the patient.”

When the researchers performed a propensity-matched analysis, they determined that transradial rescue PCI was associated with less bleeding than transfemoral rescue PCI (OR = 0.67; 95% CI, 0.52-0.87), but that there was no effect on mortality (OR = 0.81; 95% CI, 0.53-1.25).

The falsification endpoint of gastrointestinal bleeding was also lower in the transradial group (OR = 0.23; 95% CI, 0.05-0.98), meaning that “the influence of treatment-selection bias on these results cannot be ruled out,” Giri and colleagues wrote.

“I do believe that patients would benefit from a radial-first approach in these cases,” Giri told Cardiology Today. “It is important, though, that inexperienced operators build up their radial skill set through performance of less urgent cases on less sick patients initially before tackling STEMI or rescue PCI patients.”

Reasons for underuse

In a related editorial, Ehtisham Mahmud, MD, and Mitul Patel, MD, both from the division of cardiovascular medicine, Sulpizio Cardiovascular Center, University of California˗San Diego, La Jolla, California, wrote that there are several possible explanations for the underuse of transradial access in this population.

“These include inadequate training with the technique, especially in low-volume centers and amongst low-volume operators; perceived ease of femoral access in the more critically ill patients; consideration of hemodynamic support if subsequently required; or underappreciation of bleeding as an independent significant adverse event,” they wrote. – by Erik Swain

Disclosure: Giri reports no relevant financial disclosures. Please see the full study for a list of the other researchers’ relevant financial disclosures. Mahmoud reports financial ties with Abbott Vascular, Corindus, Medtronic, St. Jude Medical and The Medicines Company. Patel reports serving on the speakers’ bureau for AstraZeneca.

In patients undergoing rescue PCI after administration of fibrinolytic therapy, transradial access was used infrequently but was associated with lower rates of bleeding than transfemoral access, according to new registry data.

“We theorized that patients requiring rescue PCI would be at particularly high risk for bleeding complications,” Jay Giri, MD, MPH, assistant professor of medicine at Perelman School of Medicine and director of peripheral intervention, division of cardiovascular medicine, University of Pennsylvania, told Cardiology Today. “We wanted to understand whether the bleeding avoidance strategy of radial access was being adopted in this potentially high-risk group.”

Jay Giri, MD, MPH

Jay Giri

Giri and colleagues analyzed 9,494 patients from the National Cardiovascular Data Registry’s CathPCI Registry who underwent rescue PCI for STEMI between 2009 and 2013, stratified by access type. The outcomes of interest were in-hospital bleeding, vascular complications and mortality. They used a falsification endpoint of gastrointestinal bleeding as a way to assess for unmeasured confounding.

Transradial access and risk

The researchers found that transradial access was used in only 14.2% of cases, and compared with the transfemoral group, the transradial group was younger (P < .0001); more likely to be men (P = .0033); had higher BMI (P = .0004); was more likely to have a family history of CAD at age younger than 55 years (P = .03); had a higher glomerular filtration rate (P < .0001); and were less likely to have prior congestive HF (P = .02), cerebrovascular disease (P = .03), chronic lung disease (P = .03), hypertension (P = .03), dyslipidemia (P = .001) and CABG (P < .0001). They were also less likely to have had HF within the past 2 weeks (P = .007), cardiogenic shock (P < .0001) or cardiac arrest (P = .0007).

“We were surprised to see how few of these rescue PCI cases were approached with transradial access, given the increase in bleeding that one might expect when performing a procedure on a patient who recently received thrombolytic therapy,” Giri told Cardiology Today. “Even more interesting was the finding that among the group studied, patients at the highest risk for bleeding — those who would benefit most from transradial access — were least likely to receive that procedure. This counterintuitive finding is a demonstration of the ‘risk-treatment paradox,’ showing that doctors in these cases made treatment decisions based on what they are most comfortable with rather than what is best for the patient.”

When the researchers performed a propensity-matched analysis, they determined that transradial rescue PCI was associated with less bleeding than transfemoral rescue PCI (OR = 0.67; 95% CI, 0.52-0.87), but that there was no effect on mortality (OR = 0.81; 95% CI, 0.53-1.25).

The falsification endpoint of gastrointestinal bleeding was also lower in the transradial group (OR = 0.23; 95% CI, 0.05-0.98), meaning that “the influence of treatment-selection bias on these results cannot be ruled out,” Giri and colleagues wrote.

“I do believe that patients would benefit from a radial-first approach in these cases,” Giri told Cardiology Today. “It is important, though, that inexperienced operators build up their radial skill set through performance of less urgent cases on less sick patients initially before tackling STEMI or rescue PCI patients.”

Reasons for underuse

In a related editorial, Ehtisham Mahmud, MD, and Mitul Patel, MD, both from the division of cardiovascular medicine, Sulpizio Cardiovascular Center, University of California˗San Diego, La Jolla, California, wrote that there are several possible explanations for the underuse of transradial access in this population.

“These include inadequate training with the technique, especially in low-volume centers and amongst low-volume operators; perceived ease of femoral access in the more critically ill patients; consideration of hemodynamic support if subsequently required; or underappreciation of bleeding as an independent significant adverse event,” they wrote. – by Erik Swain

Disclosure: Giri reports no relevant financial disclosures. Please see the full study for a list of the other researchers’ relevant financial disclosures. Mahmoud reports financial ties with Abbott Vascular, Corindus, Medtronic, St. Jude Medical and The Medicines Company. Patel reports serving on the speakers’ bureau for AstraZeneca.

    Perspective

    The United States, as a community of interventionists, is new to transradial access. Although transradial access use has increased over the past 5 to 10 years, it continues to remain the less frequently used access site, especially in the more complex patients, a phenomenon known as the risk-treatment paradox. Hopefully this will change in the future. Several things can be done to increase the adoption of the transradial approach for these cases, including continuing and increasing education directed towards the interventional team and changing U.S. guidelines to emphasize the benefit of transradial access in the higher-risk subsets of patients. In my opinion, there is no patient subset where radial access has been demonstrated to be inferior. The biggest contraindication to transradial access is an untrained operator or an untrained cath lab.

    • Samir B. Pancholy, MD, FACP, FACC, FSCAI
    • Professor of Medicine, The Commonwealth Medical College Program Director, Fellowship in Cardiovascular Diseases The Wright Center for Graduate Medical Education Scranton, Pennsylvania

    Disclosures: Pancholy reports consulting and speaking for Terumo Medical.