August 2nd, 2012
Survival Better with a Radial (vs. Femoral) PCI Approach: Sleight of Hand?
Richard A. Lange, MD, MBA and L. David Hillis, MD
Patients with an ST-segment-elevation acute coronary syndrome treated with primary (or rescue) PCI have better survival when the procedure is performed using a radial approach rather than a femoral approach.
That’s one of the findings of the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) multicenter trial, in which 1001 participants with ST-segment-elevation ACS undergoing primary or rescue PCI were randomized to either a radial or a femoral approach at 4 high-volume centers.
The primary composite endpoint was the 30-day rate of net adverse clinical events (NACEs), defined as cardiac death, stroke, MI, target-lesion revascularization, or bleeding. The individual NACE components were secondary endpoints.
Results:
|
Event (30 days) |
Radial approach |
Femoral approach |
P value |
| NACEs |
13.6% |
21.0% |
0.003 |
| Cardiac death |
5.2% |
9.2% |
0.02 |
| MI |
1.2% |
1.4% |
1.00 |
| Stroke |
0.8% |
0.6% |
0.725 |
| Target-lesion revascularization |
1.2% |
1.8% |
0.604 |
| Bleeding | |||
| — access site |
2.6% |
6.8% |
0.002 |
| — major |
1.8% |
2.8% |
0.399 |
| — fatal |
0.6% |
0.6% |
0.684 |
The radial and femoral groups were similar with respect to:
– baseline and clinical variables
– periprocedural anticoagulant and antithrombotic therapies
– symptom-to-presentation and door-to-balloon times
– postprocedure MI, stroke, or target-lesion revascularization
– major or fatal bleeding
We can’t think of a plausible explanation for why the radial approach was associated with lower mortality than the femoral approach in this clinical population. Can you? Are they pulling our leg?
2 Responses to “Survival Better with a Radial (vs. Femoral) PCI Approach: Sleight of Hand?”
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Hard for me to think of an explanation, unless the access site bleeding though not major or fatal were still able to cause cardiac death. Another thought is how did they treat these access site bleeds? Could that have resulted in more deaths?
Without more data, hopefully somewhere in the supplemental information, not available yet , is difficult to talk about the way access sites were made, and after the procedures how major bleeding was avoided in the radial and not controlled in the femoral sites. As a primary care physician, I see small differences here and there that could for me explain part of the issue if added: (I am disregarding P calculations because I am considering two groups with some variations between them)
Table 2 Baseline Patient Characteristics
Overall (N = 1,001) Femoral (n = 501) Radial (n = 500)
Clinical characteristics
Age, yrs⁎ 65 (55–76) 65 (55–77) 65 (56–75) same, but there is a CV outcome difference between sexes
Female 267 (26.7) 141 (28.1) 126 (25.2) a bit more of females had femoral access
CKD (GFR Femoral
COPD 71 (7.1) 40 (8.0) 31 (6.2) again, slightly more femoral access patients
Peripheral arterial disease 143 (14.3) 68 (13.6) 75 (15.0) more radial site patients.
Previous myocardial infarction, 141 (14.1) 71 (14.2) 70 (14.0) almost same
Previous cerebrovascular accident 41 (4.1) 22 (4.4) 19 (3.8) Slightly more femoral, had Cholesterol, COPD, CKD, etc, had them continued and monitored during the hospitalization and the first month post procedure and ACS/MI. In my humble opinion, the population that had the procedure done across the femoral skin were sicker as a group than the ones that had it done radially and we might be talking here about a&o.