Radial access gains ground over femoral route for PCI

By Eleanor McDermid

A meta-analysis supports that radial access delivers better outcomes and improved safety than femoral access in patients undergoing percutaneous coronary intervention (PCI).

The study by Giuseppe Ferrante (Humanitas Research Hospital, Rozzano, Italy) and colleagues, which is published in JACC: Cardiovascular Interventions, includes 24 randomised trials with 22,843 participants.

Overall, use of radial rather than femoral access was associated with a significant 29% reduction in all-cause mortality (in-hospital or at 30 days), a 16% reduction in major adverse cardiovascular events and a 47% reduction in the risk of major bleeding.

The findings were consistent across most subgroups, although patients with stable coronary artery disease seemed to benefit most from radial access in terms of reduced bleeding risk.

John Bittl (Munroe Regional Medical Center, Ocala, Florida, USA) writes in an accompanying editorial that the evidence supporting radial access is "solid but not unshakeable", noting that some of the included studies did not meet their superiority endpoints.

Rates of myocardial infarction and stroke were similar regardless of the route of access, which Bittl describes as "reassuring".

However, in a prespecified analysis of the multicentre RIVAL and MATRIX studies, the team found that the benefits of radial access were limited to patients treated in centres with extensive radial experience.

Bittl expands on the point, saying that "[a]lthough the introduction of radial access for PCI has been a major advance, this approach is not ideal for every procedure or every practitioner".

He says that younger practitioners will probably be more comfortable, and therefore more successful, with radial access, when compared with senior practitioners "who know femoral anatomy intimately, have performed tens of thousands of transfemoral PCIs safely, and get frustrated during transradial PCI by the occasional aortic arch that directs catheters into the descending aorta."

Also, Bittl notes that radial access is less suited for certain patients, such as those with unknown bypass graft anatomy, small radial arteries or who require large transfemoral devices or haemodynamic support, although he acknowledges that "these groups represent a small proportion of patients undergoing PCI in contemporary practice."

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