Heart: Transradial PCI for STEMI gets thumbs up
“Radial access was reintroduced into clinical practice just over 20 years ago and used for PCI shortly after,” Mamas A. Mamas, MD, of the Manchester Heart Centre, Manchester Royal Infirmary in Manchester, England, and colleagues wrote. “Over this time period extensive data have accumulated confirming that the technique is preferred by patients, reduces procedural costs, may protect against renal complications such as contrast-induced nephropathy and access site complication rates.”
To compare the impact of access sites on mortality, MACE rates and major bleeding, Mamas et al performed a meta-analysis using Medline and Embase databases.
The researchers chose nine studies dated from 2003 to 2011 and included a total of 2,988 STEMI patients. The study’s main endpoints were mortality, MACE rates, major bleeding and access site complications. The researchers compared transradial versus transfemoral access route outcomes.
Within the studies, 1,460 patients underwent transradial PCI and 1,517 patients underwent transfemoral PCI. Mamas et al reported 28 deaths in the transradial arm and 54 in the femoral group. MACE occurred in 47 patients who underwent radial PCI and 77 who underwent femoral PCI. Major bleeding events occurred in 18 and 33 patients, respectively.
The authors reported that the decrease in mortality seen with the transradial approach was associated with a parallel reduction in major access site complications and a reduction in major bleeds.
“Our meta-analysis demonstrated a trend toward a reduction in major bleeding, although risk of major bleeding even if performed through the transradial route in the setting of STEMI still remains significant,” the authors wrote.
Mamas et al outlined the following reasons:
- Transradial access does not eliminate all bleeding after PCI;
- Major bleeding complications comprise both access site and non-access site complications; and
- Adoption of the transradial route would only be expected to reduce bleeding complications from the access site.
“The prognostic implications of non-access site-related bleeds are greater than those of access site-related bleeds, hence an intervention that reduces only the latter will have a smaller effect on mortality outcomes than an intervention influencing non-access site-related bleeding rates,” the authors noted.
“These data suggest that PCI patients will benefit from the adoption of safest access site practice (use of the transradial approach) in combination with an anti-thrombotic regimen optimized to preserve anti-ischemic efficacy but minimize systemic bleeding.”
The researchers noted that the mechanism in which the transradial approach reduces mortality and MACE rates in STEMI patients may be related to the prevention of bleeds and access site complications. However, the authors also noted that operator experience may play a role in preventing MACE.
“There is an urgent need for such a trial in view of the potential for radial access to reduce mortality and MACE,” the authors summed. “Until such a trial is available, our meta-analysis provides the best available data and supports the use of radial access for primary PCI reinforcing the view of earlier editorialists.”