title: Transradial versus transfemoral percutaneous coronary intervention in acute coronary syndromes: re-evaluation of the current body of evidence.
abstract: Recent literature has argued the superiority of radial access compared with femoral access for percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS). Three particular trials-RIVAL (Radial Versus Femoral Access for Coronary Intervention), RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome), and STEMI-RADIAL (ST Elevation Myocardial Infarction Treated by Radial or Femoral Approach-Randomized Multicenter Study Comparing Radial Versus Femoral Approach in Primary PCI)-demonstrated lower rates of bleeding and vascular complications with the transradial approach. Bleeding is a major independent predictor of negative long-term outcomes including death, predisposes patients to transfusions, and attenuates the ability to administer cardioprotective post-procedural anticoagulation. These trials, however, employed suboptimal antithrombotic practices. Namely, the dose of heparin and percent of patients on glycoprotein IIb/IIIa inhibitors were unnecessarily high, and a paucity of patients were on bivalirudin, which decreases bleeding and improves outcomes compared with heparin and glycoprotein IIb/IIIa inhibitors. The use of larger gauge catheters in femoral access patients predisposed them to major bleeding and its subsequent complications. In addition, these trials were carried forth in high-volume transradial centers, further limiting the ability to generalize the findings to most PCI centers. These are important considerations especially for high-risk and ACS patients, in whom the negative implications of major bleeding are even greater. Without an optimized design, the applications of the trial findings are uncertain. Ultimately, a trial comparing femoral versus radial access in patients on bivalirudin, potent oral antiplatelet medication, and without adjunctive glycoprotein IIb/IIIa inhibitors is needed to assess outcomes based on access site alone.
authors.affiliation: Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California. Electronic address: michaelsblee@gmail.com.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Lee
authors.forename: Michael
authors.initials: M
authors.lastname: Wolfe
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D000925:Anticoagulants / Q000627:therapeutic use; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D019317:Evidence-Based Medicine; D005263:Femoral Artery; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D018579:Patient Selection; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D017534:Radial Artery; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors
keywords: ACS; PCI; ST-segment elevation myocardial infarction; STEMI; TFI; TRI; acute coronary syndrome; bleeding; percutaneous coronary intervention; transfemoral intervention; transradial intervention; vascular access