June 10th, 2013

Dramatic Increase in Use of Radial Artery Access for PCI in the U.S.

In the last six years interventional cardiologists have dramatically increased their use of radial access for PCI, according to a retrospective study published in Circulation. Using data from the CathPCI registry on more than 2.8 million procedures between January 2007 and September 2012, Dmitriy Feldman and colleagues found that radial access PCI increased 13-fold, from a negligible 1.2% at the beginning of the study to 16.1% at the end.

Observational data from the registry confirmed findings from earlier studies. There were fewer bleeding complications (2.67% versus 6.08%) and vascular complications (0.16% versus 0.45%) in the radial access PCI group compared with the femoral access PCI group. These differences remained significant after adjusting for differences between the groups. On the other hand, fluoroscopy times were longer in the radial access group (14.2 minutes versus 11.1 minutes).

 The growth of radial access PCI has not been equally distributed across regions and subgroups. Approximately 13% of hospitals performed no radial access procedures. Radial access is used more often in the Northeast and is used less often in certain high-risk groups, including elderly patients 75 years of age or greater, women, and patients with acute coronary syndromes (ACS). But, the authors note, these high-risk groups may derive the greatest benefit from radial access in terms of absolute risk reduction in bleeding and vascular complications. Adoption of radial access PCI in STEMI may be hindered by “concerns over metrics related to rapid reperfusion (door-to-balloon time).”

A major reason for the slow adoption of radial access PCI is that interventional cardiologists need to learn the procedure and undergo a learning curve. Other potential barriers include the fear of lower success rates and the need in some cases for crossover to femoral access.

The authors discussed evidence suggesting that radial access PCI may be associated with a decrease in mortality, but acknowledge that “the mechanisms underlying this benefit remain unclear.” They concluded that “wider adoption of r-PCI in interventional practice, particularly in higher-risk patients, presents an opportunity to potentially improve overall PCI safety.”

In an editorial published in the American Heart Association’s open-access journal, Sunil Rao (also an author of the Circulation paper) and Mitch Krucoff offer their recommendations for bringing radial access to more higher-risk patients:

The patients at highest risk for access site bleeding and vascular complications after PCI are those who stand to gain the most from the radial approach. Once the learning curve for transradial PCI is overcome, developing a ‘radial first’ approach can minimize or even eliminate the risk‐treatment paradox. Given the amount of evidence supporting the benefits of radial access, interventional cardiologists should embrace the radial approach, do it often, become proficient at it, and use it as an opportunity to obtain the best outcomes.”



Comments are closed.