Study confirms recommendation for radial access PCI in women

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 - Transradial PCI
A coronary angiogram taken via the radial approach.
Source: Sunil V. Rao, MD.

Women undergoing coronary angiography and, if indicated, PCI are more likely to experience severe bleeding and access-site complications than men, but intervening through the radial artery substantially reduced those events, according to data from the MATRIX trial.

These findings support the use of radial access over transfemoral access in all patients with acute coronary syndrome (ACS) regardless of sex, Giuseppe Gargiulo, MD, and colleagues wrote in JACC: Cardiovascular Interventions.

Gargiulo et al. studied 8,404 patients (26.6 percent women) randomized to either transfemoral or transradial access. It is the largest randomized trial to date comparing the two methods.

Although women were 36 percent more likely to experience access site bleeding, 83 percent more likely to experience severe bleeding and 44 percent more likely to require transfusion, the researchers found there were significant reductions in major adverse cardiovascular and cerebrovascular events (MACCE) and major bleeding events when the radial approach was employed.

European Society of Cardiology guidelines currently favor radial over femoral access for non-ST segment elevated ACS, but women have traditionally received radial interventions less often than men due to anatomical concerns, two Canadian cardiologists pointed out in an accompanying editorial. The smaller artery in women poses potential technical challenges and is more prone to spasm during invasive management.

But even though these issues may have contributed to a higher crossover rate from radial to femoral access in women than men (7.6 percent vs. 5.2 percent in MATRIX), the reduction in adverse events was compelling enough for the authors to endorse a radial-first approach. And in procedures that were completed, the overall duration was shorter with similar fluoroscopy time in women—suggesting no additional sex-specific challenges occurred once vascular access was achieved.

“Overall, present findings contribute to support the concept that radial access should be preferred over the femoral access, adding to the current knowledge firm evidence that this approach is applicable to both male and female patients, and that probably it is even more beneficial in women who are characterized by increased risk of bleeding and access site related complications,” Gargiulo and colleagues wrote. “Therefore, efforts should be done to increase the adoption of radial access, but at the same time improving the operators’ training, which is fundamental to reach the most appropriate skills, particularly in women where radial access might be more challenging due to anatomical reasons.”

The editorialists agreed, pointing out the MATRIX trial is the first comparing radial and femoral access with enough female participants to draw statistically powerful conclusions for women.

“With current imaging equipment and miniaturized techniques, operators should now offer radial access to all, especially to women, who might benefit most from it,” wrote Guillaume Plourde, MD, PhD, and Olivier F. Bertrand, MD, PhD, both with the Quebec Heart-Lung Institute.

Garguilo et al. pointed out the centers participating in their study had operators who were experienced in both modes of access, so their results may not be generalizable to centers performing lower volumes of radial procedures.