Choice of arterial access site and outcomes in patients with acute coronary syndromes managed with an early invasive strategy: the ACUITY trial.
OBJECTIVE
The purpose of this study was to evaluate the impact of arterial access site on bleeding and ischaemic outcomes, overall and by treatment strategy, in patients with acute coronary syndromes (ACS).


RESULTS
In the ACUITY trial, 13,819 patients with moderate and high-risk ACS were randomised to either heparin (unfractionated or enoxaparin) plus a glycoprotein IIb/IIIa inhibitor (GPI), bivalirudin plus a GPI, or bivalirudin alone. Per operator choice, femoral access was utilised in 11,989 patients (93.8%) and radial access in 798 patients (6.2%). There was no significant difference in composite ischaemia between the radial and femoral approaches at 30 days (8.1% vs 7.5%, p=0.18) or 1 year (14.7% vs 15.5%, p=0.77), although fewer major bleeding complications occurred with the use of radial access (3.0%vs4.8%, p=0.03). Use of bivalirudin monotherapy was associated with significantly less 30-day major bleeding than heparin plus GPI after femoral access (3.0% vs 5.8%, p<0.0001), but not with radial access (4.2% vs 2.2%, P=0.19). Major or minor organ bleeding was reduced with bivalirudin monotherapy compared to heparin plus GPI to a similar extent with both femoral (4.1% vs 7.4%, P<0.0001) and radial (4.9% vs 7.2%, P=0.26) access.


CONCLUSIONS
Transradial compared to femoral arterial access is associated with similar rates of composite ischaemia and with fewer major bleeding complications in patients with ACS managed invasively. Bivalirudin monotherapy compared to heparin plus GPIs significantly reduces access site related major bleeding complications with femoral but not radial artery access, though non-access site related bleeding is reduced by bivalirudin monotherapy in all patients.
Hamon
Martial
M
Service des Maladies du Coeur et des Vaisseaux, Centre Hospitalier Universitaire de Caen, Caen, France. hamon-m@chu-caen.fr
Rasmussen
Lars H
LH
Manoukian
Steven V
SV
Cequier
Angel
A
Lincoff
Michael A
MA
Rupprecht
Hans-Jürgen
HJ
Gersh
Bernard J
BJ
Mann
Tift
T
Bertrand
Michel E
ME
Mehran
Roxana
R
Stone
Gregg W
GW
D054058:Acute Coronary Syndrome / Q000628:therapy*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects* / Q000379:methods; D000925:Anticoagulants / Q000008:administration & dosage*; D001803:Blood Transfusion; D002406:Catheterization, Peripheral / Q000009:adverse effects*; D004359:Drug Therapy, Combination; D017984:Enoxaparin / Q000008:administration & dosage; D005260:Female; D005263:Femoral Artery; D006470:Hemorrhage / Q000209:etiology / Q000517:prevention & control*; D006629:Hirudins / Q000008:administration & dosage; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000209:etiology / Q000517:prevention & control*; D010446:Peptide Fragments / Q000008:administration & dosage; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D016016:Proportional Hazards Models; D011677:Punctures; D017534:Radial Artery; D011994:Recombinant Proteins / Q000008:administration & dosage; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
D000925:Anticoagulants; D017984:Enoxaparin; D006629:Hirudins; D010446:Peptide Fragments; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011994:Recombinant Proteins; C074619:bivalirudin