January 29th, 2013

ESC Gives a Shot in the Arm to Radial Access for PCI Procedures: A New Default?

Radial access is now the preferred approach for percutaneous coronary interventions, according to a consensus document from the European Society of Cardiology and other European organizations and published online in EuroIntervention. However, at least one prominent U.S. interventional cardiologist thinks the “hard benefits” of radial access “are more controversial,” though he supports increased use of the newer approach.

The popularity of the radial-artery approach has grown in recent years, in large part provoked by the desire to reduce the bleeding associated with the femoral approach. This concern is heightened in acute interventions in which the use of anticoagulants and antiplatelets increase the bleeding risk. Patients treated via the radial approach are able to stand up and move around much faster than patients who are treated via the femoral approach.

The chief limitation of the radial approach is the smaller size of the radial artery, requiring smaller catheters that are not suitable in a small number of cases. The radial approach also requires retraining for physicians who have always used the femoral approach. Physicians who employ the radial approach must also know how to use the femoral approach. The European document notes that “proficiency in the femoral approach is required because it may be needed as a bailout strategy or when large guiding catheters are required.”

Another drawback to the radial approach is that the amount of radiation exposed to the patient may increase, especially in the first few procedures performed with the new approach.

In an ESC press release, co-author Marco Tubaro said:

 “The radial approach strongly reduces the bleeding complication at the site of the procedure. The reduction in bleeding translates into a reduction in events and even into a reduction in mortality, particularly in patients with ST-elevation myocardial infarction (STEMI).”

The first author of the document, Martial Hamon, said:

“Overall I think there is a consensus now that the radial arteries can be used as the default access site for PCI. However we need to be aware of remaining concerns, for example risk of stroke and radiation exposure, especially during the learning curve. There also remains the issue of non-access site bleeding whatever the access site used. These issues are outlined in the paper.”

Columbia University’s Ajay Kirtane provided the following comment to CardioBrief:

“Transradial access is an important skill to learn, and I am certainly a believer in this approach (using it as the default approach for the majority of my patients). In fact, I am one of the directors of an upcoming course sponsored by the Cardiovascular Research Foundation dedicated to teaching this approach to physicians (transradialcourse.com). I do feel, however, that the evidence demonstrating reductions in mortality and even major bleeding complications is not as clearcut as is often presented. For one, the pharmacologic regimens used in these trials were more potent than many U.S. operators use (e.g., predominance of heparin plus glycoprotein IIb/IIIa inhibitors instead of bivalirudin), and additionally, vascular closure devices were rarely used in these trials. Additionally, if one looks critically at some of the radial vs. femoral trials (even in STEMI patients), there are some puzzling findings. For example, in RIFLE-STEACS, there was a 4% reduction in cardiac death and a 4.4% reduction in bleeding but virtually no difference in other outcomes. That would suggest that the reduction in cardiac death was entirely attributable to a reduction in bleeding, and that practically all bleeding events caused a death, which is hard to fathom. Thus, while I believe that there are other clear and notable benefits to the transradial approach (patient comfort, less bruising, early ambulation time) that are supported by the evidence, the ‘hard benefits’ of transradial access are more controversial, in my opinion. I do concur that it is essential for operators to train in both techniques, and that there will be situations where femoral access will clearly be preferred.”


2 Responses to “ESC Gives a Shot in the Arm to Radial Access for PCI Procedures: A New Default?”

  1. I asked Sunil Rao of Duke University to respond to a few questions about radial access:

    Do you think radial access should be the default choice?

    I believe that it should be first choice since the data show that it is associated with a significant reduction in access site bleeding and vascular complications. Having said that, I think that training is the big issue. Operators need to learn radial approach and then apply it regularly in their practice so that they can become proficient. It shouldn’t be a hobby that they dabble in.

    Are there different issues in the US than in Europe?

    The big difference is the low uptake of radial in the US relative to some European countries. We tend to think of Europe as one homogenous area, but there are differences even within Europe with respect to the proportion of cases performed radially. Some countries like France are very high, and others are lower, but I think the US is probably lower than most European countries. There has been a significant increase in radial cases in the US during the past four years but femoral is still the predominant approach here.

    What is the current percentage of radial cases in the US?

    The current rate is between 11-13%, which is about a 10-fold increase since 2007. The number of training opportunities has increased as well, but we could do better. I think the fellowship programs are responding and perhaps the change in the US will be driven by the next generation of interventionalists.


  2. Judith Andersen, AB, MD says:

    I agree with Dr Rao. Willingness to pursue the radial route depends upon experience with the narrower lumen catheters necessary for this approach, and busy non-academic US cardiologists may not feel it reasonable to be re-instructed in this approach. Academic referral centers and large cardiology practices with high outcome standards are likely to be the sites where participation in clinical trials is frequent and pursuit of this approach is taught and therefore more prevalent. From the perspective of a coagulation consultant, the use of this approach permits life-saving interventions in patients whose baseline hemogram– including severe thrombocytopenia (platelet counts of <5,000/mcl) and renal function would preclude the average cardiologist's even attempting an intervention. Would welcome others'opinions.