Radial access stents should be default approach

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Access through the wrist, or radial access, when inserting stents to restore blood flow in heart disease patients, has fewer complications and should be the default approach over access through the groin, or femoral access, according to a meta-analysis.

Researchers from the Humanitas Research Hospital, Humanitas Clinical and Research Centre, Rozzano, ItalyDuke Clinical Research Institute, St. Michael’s Hospital, University of Toronto, Institute of Primary Health Care, University of Bern, Humanitas Mater Domini, Castellanza, Italy, Hamilton Health Sciences, Quebec Heart-Lung Institute and Bern University Hospital, looked at 24 studies, enrolling 22,843 participants to conduct a comprehensive meta-analysis across the spectrum of heart disease and determined there was “strong to very strong” evidence that major bleeding and vascular complications were reduced and “moderate to strong” evidence that all cause death rates were reduced when using radial access versus femoral access.

Researchers concluded that the benefits of radial access support it being the default approach for all heart disease patients needing this procedure.

Radial access is a newer procedure and it involves a longer learning curve to develop the technical skills necessary. However, JACC: Cardiovascular Interventions editor-in-chief Dr Spencer King, said: “As radial access is increasingly adopted, the benefits seen in trials has been weighed against the learning curve necessary for some operators. This most complete analysis of the value of radial access may convince some doubters to switch.”

Objectives: The aim of this study was to provide a quantitative appraisal of the effects on clinical outcomes of radial access for coronary interventions in patients with coronary artery disease (CAD).
Background: Randomized trials investigating radial versus femoral access for percutaneous coronary interventions have provided conflicting evidence. No comprehensive quantitative appraisal of the risks and benefits of each approach is available across the whole spectrum of patients with stable or unstable CAD.
Methods: The PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for randomized trials comparing radial versus femoral access for coronary interventions. Data were pooled by meta-analysis using a fixed-effects or a random-effects model, as appropriate. Pre-specified subgroup analyses according to clinical presentation, in terms of stable CAD, non–ST-segment elevation acute coronary syndromes, or ST-segment elevation myocardial infarction were performed.
Results: Twenty-four studies enrolling 22,843 participants were included. Compared with femoral access, radial access was associated with a significantly lower risk for all-cause mortality (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.59 to 0.87; p = 0.001, number needed to treat to benefit [NNTB] = 160), major adverse cardiovascular events (OR: 0.84; 95% CI: 0.75 to 0.94; p = 0.002; NNTB = 99), major bleeding (OR: 0.53; 95% CI: 0.42 to 0.65; p < 0.001; NNTB = 103), and major vascular complications (OR: 0.23; 95% CI: 0.16 to 0.35; p < 0.001; NNTB = 117). The rates of myocardial infarction or stroke were similar in the 2 groups. Effects of radial access were consistent across the whole spectrum of patients with CAD for all appraised endpoints.
Conclusions: Compared with femoral access, radial access reduces mortality and MACE and improves safety, with reductions in major bleeding and vascular complications across the whole spectrum of patients with CAD.

Giuseppe Ferrante, Sunil V Rao, Peter Jüni, Bruno R Da Costa, Bernhard Reimers, Gianluigi Condorelli, Angelo Anzuini, Sanjit S Jolly, Olivier F Bertrand, Mitchell W Krucoff, Stephan Windecker, Marco Valgimigli

American College of Cardiology material
JACC: Cardiovascular Interventions abstract

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