Advertisement

Meta-Analysis of Radial Versus Femoral Access for Percutaneous Coronary Interventions in Non–ST-Segment Elevation Acute Coronary Syndrome

Published:November 05, 2015DOI:https://doi.org/10.1016/j.amjcard.2015.10.039
      Radial access for percutaneous coronary intervention (PCI) has been shown to reduce mortality and vascular complications compared to femoral access in patients with ST-segment elevation myocardial infarction. However, efficacy and safety of radial access PCI in non–ST-segment elevation acute coronary syndrome (NSTE ACS) is not well understood. A systematic search of electronic databases was performed through July 2015 to search and identify relevant studies. We evaluated the following short-term outcomes: all-cause mortality, major bleeding, access site bleeding, and need for blood transfusions. In addition, we evaluated 1-year mortality. Studies were pooled using random effects model. Nine studies including a total of 220,126 patients (radial approach: 94,663 patients [43%], femoral approach: 125,463 patients [57%]) were included in the analysis. On pooled analysis, no significant difference in incidence of short-term all-cause mortality was found between radial and femoral access (odds ratio [OR] 0.78, 95% CI 0.57 to 1.07, p = 0.12). Radial access was associated with significant reduction in major bleeding (OR 0.52, 95% CI 0.36 to 0.73, p = 0.0002), access-site bleeding (OR 0.41, 95% CI 0.22 to 0.78, p = 0.007), and need for blood transfusions (OR 0.61, 95% CI 0.41 to 0.91, p = 0.02). Furthermore, the 1-year mortality was significantly lower in radial approach (OR 0.72, 95% CI 0.55 to 0.95, p = 0.02). In conclusion, in patients with non–ST-segment elevation acute coronary syndrome undergoing PCI, radial access is associated with decreased bleeding and access-site complications.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Yeh R.W.
        • Sidney S.
        • Chandra M.
        • Sorel M.
        • Selby J.V.
        • Go A.S.
        Population trends in the incidence and outcomes of acute myocardial infarction.
        N Engl J Med. 2010; 362: 2155-2165
        • Mehta S.R.
        • Cannon C.P.
        • Fox K.A.
        • Wallentin L.
        • Boden W.E.
        • Spacek R.
        • Widimsky P.
        • McCullough P.A.
        • Hunt D.
        • Braunwald E.
        • Yusuf S.
        Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials.
        JAMA. 2005; 293: 2908-2917
        • Biondi-Zoccai G.G.
        • Abbate A.
        • Agostoni P.
        • Testa L.
        • Burzotta F.
        • Lotrionte M.
        • Trani C.
        • Biasucci L.M.
        Long-term benefits of an early invasive management in acute coronary syndromes depend on intracoronary stenting and aggressive antiplatelet treatment: a metaregression.
        Am Heart J. 2005; 149: 504-511
        • Bertrand O.F.
        • Belisle P.
        • Joyal D.
        • Costerousse O.
        • Rao S.V.
        • Jolly S.S.
        • Meerkin D.
        • Joseph L.
        Comparison of transradial and femoral approaches for percutaneous coronary interventions: a systematic review and hierarchical Bayesian meta-analysis.
        Am Heart J. 2012; 163: 632-648
        • Jolly S.S.
        • Yusuf S.
        • Cairns J.
        • Niemela K.
        • Xavier D.
        • Widimsky P.
        • Budaj A.
        • Niemela M.
        • Valentin V.
        • Lewis B.S.
        • Avezum A.
        • Steg P.G.
        • Rao S.V.
        • Gao P.
        • Afzal R.
        • Joyner C.D.
        • Chrolavicius S.
        • Mehta S.R.
        • RIVAL Trial Group
        Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial.
        Lancet. 2011; 377: 1409-1420
        • Valgimigli M.
        • Gagnor A.
        • Calabro P.
        • Frigoli E.
        • Leonardi S.
        • Zaro T.
        • Rubartelli P.
        • Briguori C.
        • Ando G.
        • Repetto A.
        • Limbruno U.
        • Cortese B.
        • Sganzerla P.
        • Lupi A.
        • Galli M.
        • Colangelo S.
        • Ierna S.
        • Ausiello A.
        • Presbitero P.
        • Sardella G.
        • Varbella F.
        • Esposito G.
        • Santarelli A.
        • Tresoldi S.
        • Nazzaro M.
        • Zingarelli A.
        • de Cesare N.
        • Rigattieri S.
        • Tosi P.
        • Palmieri C.
        • Brugaletta S.
        • Rao S.V.
        • Heg D.
        • Rothenbuhler M.
        • Vranckx P.
        • Juni P.
        • MATRIX Investigators
        Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial.
        Lancet. 2015; 385: 2465-2476
        • Higgins J.P.
        • Green S.
        Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011].
        The Cochrane Collaboration, 2011 (Available at:) (Accessed January 7, 2014)
        • DerSimonian R.
        • Laird N.
        Meta-analysis in clinical trials.
        Control Clin Trials. 1986; 7: 177-188
        • Higgins J.P.
        • Thompson S.G.
        Quantifying heterogeneity in a meta-analysis.
        Stat Med. 2002; 21: 1539-1558
        • Begg C.B.
        • Mazumdar M.
        Operating characteristics of a rank correlation test for publication bias.
        Biometrics. 1994; 50: 1088-1101
        • Duval S.
        • Tweedie R.
        Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis.
        Biometrics. 2000; 56: 455-463
        • Mehta S.R.
        • Jolly S.S.
        • Cairns J.
        • Niemela K.
        • Rao S.V.
        • Cheema A.N.
        • Steg P.G.
        • Cantor W.J.
        • Dzavik V.
        • Budaj A.
        • Rokoss M.
        • Valentin V.
        • Gao P.
        • Yusuf S.
        • RIVAL Investigators
        Effects of radial versus femoral artery access in patients with acute coronary syndromes with or without ST-segment elevation.
        J Am Coll Cardiol. 2012; 60: 2490-2499
        • Ratib K.
        • Mamas M.A.
        • Anderson S.G.
        • Bhatia G.
        • Routledge H.
        • De Belder M.
        • Ludman P.F.
        • Fraser D.
        • Nolan J.
        • British Cardiovascular Intervention Society and the National Institute for Cardiovascular Outcomes Research
        Access site practice and procedural outcomes in relation to clinical presentation in 439,947 patients undergoing percutaneous coronary intervention in the United kingdom.
        JACC Cardiovasc Interv. 2015; 8: 20-29
        • Cantor W.J.
        • Mahaffey K.W.
        • Huang Z.
        • Das P.
        • Gulba D.C.
        • Glezer S.
        • Gallo R.
        • Ducas J.
        • Cohen M.
        • Antman E.M.
        • Langer A.
        • Kleiman N.S.
        • White H.D.
        • Chisholm R.J.
        • Harrington R.A.
        • Ferguson J.J.
        • Califf R.M.
        • Goodman S.G.
        Bleeding complications in patients with acute coronary syndrome undergoing early invasive management can be reduced with radial access, smaller sheath sizes, and timely sheath removal.
        Catheter Cardiovasc Interv. 2007; 69: 73-83
        • Hamon M.
        • Rasmussen L.H.
        • Manoukian S.V.
        • Cequier A.
        • Lincoff M.A.
        • Rupprecht H.J.
        • Gersh B.J.
        • Mann T.
        • Bertrand M.E.
        • Mehran R.
        • Stone G.W.
        Choice of arterial access site and outcomes in patients with acute coronary syndromes managed with an early invasive strategy: the ACUITY trial.
        EuroIntervention. 2009; 5: 115-120
        • Klutstein M.W.
        • Westerhout C.M.
        • Armstrong P.W.
        • Giugliano R.P.
        • Lewis B.S.
        • Gibson C.M.
        • Lutchmedial S.
        • Widimsky P.
        • Steg P.G.
        • Dalby A.
        • Zeymer U.
        • Van de Werf F.
        • Harrington R.A.
        • Newby L.K.
        • Rao S.V.
        Radial versus femoral access, bleeding and ischemic events in patients with non-ST-segment elevation acute coronary syndrome managed with an invasive strategy.
        Am Heart J. 2013; 165: 583-590.e1
        • Iqbal M.B.
        • Arujuna A.
        • Ilsley C.
        • Archbold A.
        • Crake T.
        • Firoozi S.
        • Kalra S.
        • Knight C.
        • Lim P.
        • Malik I.S.
        • Mathur A.
        • Meier P.
        • Rakhit R.D.
        • Redwood S.
        • Whitbread M.
        • Bromage D.
        • Rathod K.
        • Wragg A.
        • MacCarthy P.
        • Dalby M.
        • London Heart Attack Centre Group Investigators
        Radial versus femoral access is associated with reduced complications and mortality in patients with non-ST-segment-elevation myocardial infarction: an observational cohort study of 10,095 patients.
        Circ Cardiovasc interventions. 2014; 7: 456-464
        • Park K.H.
        • Jeong M.H.
        • Ahn Y.
        • Jung S.S.
        • Kim M.H.
        • Yang H.M.
        • Yoon J.
        • Rha S.W.
        • Park K.S.
        • Han K.R.
        • Cho B.R.
        • Cha K.S.
        • Kim B.O.
        • Hyon M.S.
        • Shin W.Y.
        • Choe H.
        • Bae J.W.
        • Kim H.Y.
        • Trans-Radial Intervention Registry Investigators
        The impact of vascular access for in-hospital major bleeding in patients with acute coronary syndrome at moderate- to very high-bleeding risk.
        J Korean Med Sci. 2013; 28: 1307-1315
        • Sciahbasi A.
        • Pristipino C.
        • Ambrosio G.
        • Sperduti I.
        • Scabbia E.V.
        • Greco C.
        • Ricci R.
        • Ferraiolo G.
        • Di Clemente D.
        • Giombolini C.
        • Lioy E.
        • Tubaro M.
        Arterial access-site-related outcomes of patients undergoing invasive coronary procedures for acute coronary syndromes (from the ComPaRison of Early Invasive and Conservative Treatment in Patients with Non-ST-ElevatiOn Acute Coronary Syndromes [PRESTO-ACS] Vascular Substudy).
        Am J Cardiol. 2009; 103: 796-800
        • Jang J.S.
        • Jin H.Y.
        • Seo J.S.
        • Yang T.H.
        • Kim D.K.
        • Kim D.K.
        • Kim D.I.
        • Cho K.I.
        • Kim B.H.
        • Park Y.H.
        • Je H.G.
        • Kim D.S.
        The transradial versus the transfemoral approach for primary percutaneous coronary intervention in patients with acute myocardial infarction: a systematic review and meta-analysis.
        EuroIntervention. 2012; 8: 501-510
        • Karrowni W.
        • Vyas A.
        • Giacomino B.
        • Schweizer M.
        • Blevins A.
        • Girotra S.
        • Horwitz P.A.
        Radial versus femoral access for primary percutaneous interventions in ST-segment elevation myocardial infarction patients: a meta-analysis of randomized controlled trials.
        JACC Cardiovasc interventions. 2013; 6: 814-823
        • De Luca G.
        • Schaffer A.
        • Wirianta J.
        • Suryapranata H.
        Comprehensive meta-analysis of radial vs femoral approach in primary angioplasty for STEMI.
        Int J Cardiol. 2013; 168: 2070-2081
        • Mathews R.
        • Peterson E.D.
        • Chen A.Y.
        • Wang T.Y.
        • Chin C.T.
        • Fonarow G.C.
        • Cannon C.P.
        • Rumsfeld J.S.
        • Roe M.T.
        • Alexander K.P.
        In-hospital major bleeding during ST-elevation and non-ST-elevation myocardial infarction care: derivation and validation of a model from the ACTION Registry®-GWTG.
        Am J Cardiol. 2011; 107: 1136-1143
        • Kontos M.C.
        • Rennyson S.L.
        • Chen A.Y.
        • Alexander K.P.
        • Peterson E.D.
        • Roe M.T.
        The association of myocardial infarction process of care measures and in-hospital mortality: a report from the NCDR®.
        Am Heart J. 2014; 168: 766-775
        • Verheugt F.W.
        • Steinhubl S.R.
        • Hamon M.
        • Darius H.
        • Steg P.G.
        • Valgimigli M.
        • Marso S.P.
        • Rao S.V.
        • Gershlick A.H.
        • Lincoff A.M.
        • Mehran R.
        • Stone G.W.
        Incidence, prognostic impact, and influence of antithrombotic therapy on access and nonaccess site bleeding in percutaneous coronary intervention.
        JACC Cardiovasc interventions. 2011; 4: 191-197
        • Rao S.V.
        • Cohen M.G.
        • Kandzari D.E.
        • Bertrand O.F.
        • Gilchrist I.C.
        The transradial approach to percutaneous coronary intervention: historical perspective, current concepts, and future directions.
        J Am Coll Cardiol. 2010; 55: 2187-2195
        • Song Y.B.
        • Hahn J.Y.
        • Kim J.H.
        • Lee S.Y.
        • Choi S.H.
        • Choi J.H.
        • Choi S.H.
        • Lee S.H.
        • Yoon J.
        • Kim Y.J.
        • Jeong M.H.
        • Gwon H.C.
        • Korea Acute Myocardial Infarction Registry Investigators
        Comparison of angiographic and other findings and mortality in non-ST-segment elevation versus ST-segment elevation myocardial infarction in patients undergoing early invasive intervention.
        Am J Cardiol. 2010; 106: 1397-1403
        • Roffi M.
        • Patrono C.
        • Collet J.P.
        • Mueller C.
        • Valgimigli M.
        • Andreotti F.
        • Bax J.J.
        • Borger M.A.
        • Brotons C.
        • Chew D.P.
        • Gencer B.
        • Hasenfuss G.
        • Kjeldsen K.
        • Lancellotti P.
        • Landmesser U.
        • Mehilli J.
        • Mukherjee D.
        • Storey R.F.
        • Windecker S.
        2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2015; ([Epub ahead of print])

      Linked Article

      • Radial Access in Non–ST-Segment Elevation Acute Coronary Syndrome
        American Journal of CardiologyVol. 117Issue 3
        • Preview
          We read the study by Bavishi et al1 recently published in the American Journal of Cardiology. The investigators systematically reviewed the current body of evidence about efficacy and safety of radial access, compared with femoral, in patients with acute coronary syndrome without persistent ST-segment elevation (NSTE-ACS) who are invasively managed. By pooling outcomes of 9 studies, they found a consistent reduction in access site–related major bleeding in the short-term period, which also translated into a statistically significant reduction in 1-year mortality.
        • Full-Text
        • PDF