Meta-analysis: Radial access intervention further reduces mortality, MACE vs. femoral access across CAD spectrum
In patients with CAD undergoing coronary intervention, access via the radial artery yielded greater decreases in all-cause mortality, MACE, major bleeding and major vascular complications compared with access via the femoral artery.
“These findings support the use of radial access as the default approach for coronary angiography followed by PCI in the whole spectrum of patients with CAD undergoing invasive management and strongly support a change in the ‘femoral first’ paradigm to a ‘radial first’ approach,” Giuseppe Ferrante, MD, PhD, from the department of interventional cardiology, Humanitas Clinical and Research Center, Milan, Italy, and colleagues wrote in JACC: Cardiovascular Interventions.
The meta-analysis included randomized controlled trials that compared radial vs. femoral access. Researchers identified 24 RCTs comprising 22,843 patients with CAD who underwent coronary angiography followed by PCI. The two primary endpoints were all-cause mortality and major bleeding. Secondary efficacy and safety outcomes included MI, stroke, MACE and vascular complications.
Overall, radial access was associated with a lower risk for all-cause mortality compared with femoral access (OR = 0.71; 95% CI, 0.58-0.87; number needed to treat to benefit = 160). Radial access also was linked to reduced risk for MACE (OR = 0.84; 95% CI, 0.75-0.94; number needed to treat to benefit = 99), major bleeding (OR = 0.53; 95% CI, 0.42-0.65; number needed to treat to benefit = 103) and major vascular complications (OR = 0.23; 95% CI, 0.16-0.34; number needed to treat to benefit = 117).
Rates of MI or stroke were not different between radial or femoral access.
A random-effects Bayesian meta-analysis yielded similar results in the comparison of radial vs. femoral access on clinical outcomes. These findings varied by endpoint in terms of the strength of evidence, with “strong to very strong” evidence for major bleeding and major vascular complications, “moderate to strong” for all-cause mortality, and “moderate” strength for MACE and net adverse clinical endpoints.
A subgroup analysis based on clinical syndrome demonstrated that the effect of radial access persisted across subgroups of CAD, NTSE-ACS and STEMI. However, a quantitative interaction suggested that the benefit of radial access for major bleeding was greater among patients with stable coronary syndromes vs. those with NTSE-ACS (P for interaction = .01) or STEMI (P for interaction = .06). In a prespecified subgroup analysis of the RIVAL and MATRIX studies, radial access, compared with femoral access, was associated with improved clinical outcomes in centers with high radial expertise, but not in centers with low radial expertise.
“In patients across the whole spectrum of [CHD], radial access improves clinical outcomes compared to femoral access, as it reduces all-cause mortality and [MACE],” the researchers wrote. “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.” – by Jennifer Byrne
Disclosure: One researcher reports receiving institutional grants from Terumo and The Medicines Company for the MATRIX trial. Another researcher reports receiving research grants to his institution from AstraZeneca, Biosensors International, Biotronik, Eli Lilly and The Medicines Company and serving as unpaid member of the steering group of trials funded by AstraZeneca, Biosensors International, Biotronik, St. Jude Medical and The Medicines Company.