Is Radial Artery Access Safer than Femoral Artery Access for PCI?
Is Radial Artery Access Safer than Femoral Artery Access for PCI?
Abstract & Commentary
By Andrew J. Boyle, MBBS, PhD Dr. Boyle is Assistant Professor of Medicine, Interventional Cardiology, University of California, San Francisco Dr. Boyle reports no financial relationships relevant to this field of study.
Source: Chase AJ, et al. Association of the arterial access site at angioplasty with transfusion and mortality: the M.O.R.T.A.L study (Mortality benefit Of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg). Heart. 2008;94:1019-1025.
Radial artery access for cardiac catheterization and percutaneous coronary intervention (PCI) results in lower rates of access site complications, bleeding, and blood transfusion than femoral artery access. Blood transfusions have been linked with excess mortality in several studies of PCI. However, the relationship between access site, transfusion, and mortality has not been completely described. Thus, Chase et al sought to examine the rates of blood transfusion and mortality in radial vs femoral arterial access for PCI.
In the largest study of radial vs femoral approach for PCI to date, Chase et al utilized the British Columbia Cardiac Registry (BCCR), which mandates data input from all percutaneous coronary interventions (PCI) performed in British Columbia. They were able to access data on all PCI procedures performed on residents of British Columbia over a seven-year period. To further strengthen their data, they cross-referenced the PCI data with a central blood transfusion registry, which captured all blood transfusions in the 10 days following the index PCI procedures.
Chase et al studied 39,386 PCI procedures in 32,822 patients. They excluded 311 patients who underwent coronary artery bypass graft (CABG) surgery within 10 days because blood transfusions were assumed to be due to the surgery in these patients. An additional 166 patients were excluded for repeat procedures on the same day or for brachial artery access. Of the remaining patients, 20.5% underwent radial artery access (n = 7,972) and 79.5% had femoral artery access (n = 30,900) for PCI. The baseline characteristics of the patients differed significantly between groups. The radial group was older, had higher BMI, and had more emergency procedures, but the femoral group may have had more high-risk patients, as they had more diabetes, more prior myocardial infarction (MI), prior procedures, renal impairment, and other co-morbidities. The indications for the PCI procedures (stable coronary artery disease vs acute coronary syndromes) did not differ between groups.
The primary outcomes of the study were blood transfusion rate and mortality at 30 days and one year. Radial artery access was associated with halving of the blood transfusion rate (1.4% vs 2.8%; p < 0.01); blood transfusion was associated with a higher mortality. Unadjusted odds ratio for 30-day mortality in those who received transfusions was 11.4, and for one-year mortality was 8.9 (p < 0.001). After logistic regression analysis to account for multiple variables, the odds ratio for mortality in patients receiving a blood transfusion remained elevated: 4.0 for 30-day mortality and 3.6 for one-year mortality (p < 0.001). To confirm the relationship between transfusion and mortality, Chase et al performed propensity score matching. Transfusion continued to be associated with higher mortality at both time-points.
Radial artery access was associated with reduced 30-day mortality (1.0% vs 1.7%; p < 0.01) and one-year mortality (2.8% vs 3.9%; p < 0.01) compared with femoral artery access. The unadjusted odds ratio for mortality using radial vs femoral access was 0.58 at 30 days and 0.64 at one year (p < 0.001). The adjusted odds ratio for mortality was 0.71 at 30 days and 0.83 at one year (p < 0.001). Chase et al conclude that radial artery access was associated with a halving of transfusion rate and a reduction in 30-day and one-year mortality, and that their data should be confirmed by other large registries and randomized prospective trials.
Commentary
A particular strength of this study is the very large number of patients and procedures documented. However, it should be noted that this is a retrospective, non-randomized analysis, and there may be significant selection bias in which patients the operators chose to perform radial vs femoral access. In addition, some important data are lacking that may affect the rates of bleeding. The use of anti-platelet and anti-thrombin therapies was not adequately documented. The size of sheaths used, the rates of femoral artery closure devices, and the duration of manual pressure and baseline coagulation parameters were also not reported. Despite these limitations, this large observational study suggests that, after accounting for baseline differences between groups, radial artery access may be safer than femoral artery access.
Radial artery access for cardiac catheterization and percutaneous coronary intervention (PCI) results in lower rates of access site complications, bleeding, and blood transfusion than femoral artery access.Subscribe Now for Access
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