title: 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.
abstract: OBJECTIVE
  Our objective was to analyze the impact of arterial access site, sheath size, timing of sheath removal, and use of access site closure devices on high-risk patients with acute coronary syndromes (ACS).
  
  
  BACKGROUND
  In the SYNERGY trial, 9,978 patients with ACS were randomly assigned to receive enoxaparin or unfractionated heparin.
  
  
  METHODS
  This analysis includes 9,404 patients for whom sheath access information was obtained for the first PCI procedure or diagnostic catheterization. Comparisons of baseline, angiographic, and procedural characteristics were carried out according to access site and sheath size.
  
  
  RESULTS
  Overall, 9,404 (94%) patients underwent angiography at a median of 21 hr (25th and 75th percentiles: 5, 42) and 4,687 (50%) underwent PCI at a median of 23 hr (6,49) of enrollment. The access site was femoral for 94.9% of cases, radial for 4.4%, and brachial for 0.7%. Radial access was associated with fewer transfusions than femoral access (0.9% vs. 4.8%, P=0.007). For femoral access, the rates of noncoronary artery bypass grafting (CABG)-related TIMI major bleeding by sheath size was 1.5% for 4 or 5 French (Fr), 1.6% for 6 Fr, 3.3% for 7 Fr, and 3.8% for >or=8 Fr (P<0.0001). After adjustment for baseline characteristics, femoral access site, larger sheath size, and delayed sheath removal were independent predictors of need for transfusion.
  
  
  CONCLUSIONS
  Smaller sheaths, radial access, and timely sheath removal may mitigate the bleeding risk associated with potent antithrombotic/platelet therapy and early catheterization.
authors.affiliation: Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. cantorw@rogers.com
authors.forename: Warren J
authors.initials: WJ
authors.lastname: Cantor
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
authors.forename: Zhen
authors.initials: Z
authors.lastname: Huang
authors.forename: Pranab
authors.initials: P
authors.lastname: Das
authors.forename: Dietrich C
authors.initials: DC
authors.lastname: Gulba
authors.forename: Stanislav
authors.initials: S
authors.lastname: Glezer
authors.forename: Richard
authors.initials: R
authors.lastname: Gallo
authors.forename: John
authors.initials: J
authors.lastname: Ducas
authors.forename: Marc
authors.initials: M
authors.lastname: Cohen
authors.forename: Elliott M
authors.initials: EM
authors.lastname: Antman
authors.forename: Anatoly
authors.initials: A
authors.lastname: Langer
authors.forename: Neal S
authors.initials: NS
authors.lastname: Kleiman
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Chisholm
authors.forename: Robert A
authors.initials: RA
authors.lastname: Harrington
authors.forename: James J
authors.initials: JJ
authors.lastname: Ferguson
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
authors.forename: Shaun G
authors.initials: SG
authors.lastname: Goodman
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D001803:Blood Transfusion / Q000706:statistics & numerical data; D016009:Chi-Square Distribution; D017023:Coronary Angiography; D020878:Device Removal; D017984:Enoxaparin / Q000627:therapeutic use; D004867:Equipment Design; D005260:Female; D005268:Femoral Vein; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006470:Hemorrhage / Q000209:etiology* / Q000517:prevention & control*; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy / Q000628:therapy*; D016896:Treatment Outcome
chemical_list: D017984:Enoxaparin; D005343:Fibrinolytic Agents; D006493:Heparin