Transradial versus transfemoral percutaneous coronary intervention in acute coronary syndromes: re-evaluation of the current body of evidence

Michael S Lee, Michael Wolfe, Gregg W Stone
JACC. Cardiovascular Interventions 2013, 6 (11): 1149-52
Recent literature has argued the superiority of radial access compared with femoral access for percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS). Three particular trials-RIVAL (Radial Versus Femoral Access for Coronary Intervention), RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome), and STEMI-RADIAL (ST Elevation Myocardial Infarction Treated by Radial or Femoral Approach-Randomized Multicenter Study Comparing Radial Versus Femoral Approach in Primary PCI)-demonstrated lower rates of bleeding and vascular complications with the transradial approach. Bleeding is a major independent predictor of negative long-term outcomes including death, predisposes patients to transfusions, and attenuates the ability to administer cardioprotective post-procedural anticoagulation. These trials, however, employed suboptimal antithrombotic practices. Namely, the dose of heparin and percent of patients on glycoprotein IIb/IIIa inhibitors were unnecessarily high, and a paucity of patients were on bivalirudin, which decreases bleeding and improves outcomes compared with heparin and glycoprotein IIb/IIIa inhibitors. The use of larger gauge catheters in femoral access patients predisposed them to major bleeding and its subsequent complications. In addition, these trials were carried forth in high-volume transradial centers, further limiting the ability to generalize the findings to most PCI centers. These are important considerations especially for high-risk and ACS patients, in whom the negative implications of major bleeding are even greater. Without an optimized design, the applications of the trial findings are uncertain. Ultimately, a trial comparing femoral versus radial access in patients on bivalirudin, potent oral antiplatelet medication, and without adjunctive glycoprotein IIb/IIIa inhibitors is needed to assess outcomes based on access site alone.

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