title: Access site practice and procedural outcomes in relation to clinical presentation in 439,947 patients undergoing percutaneous coronary intervention in the United kingdom.
abstract: OBJECTIVE
  This study sought to determine the relationships among access site practice, clinical presentation, and procedural outcomes in a large patient population.
  
  
  BACKGROUND
  Transradial access (TRA) has been associated with improved patient outcomes in selected populations in randomized trials. It is unclear whether these outcomes are achievable in clinical practice.
  
  
  METHODS
  Using the BCIS (British Cardiovascular Intervention Society) database, we investigated outcomes for percutaneous coronary intervention procedures undertaken between 2007 and 2012 according to access site practice. Patients were categorized as stable, non-ST-segment elevation acute coronary syndrome (NSTEACS) and ST-elevation acute coronary syndrome (STEACS). The impact of access site on 30-day mortality, major adverse cardiac events, bleeding, and arterial access site complications was studied.
  
  
  RESULTS
  Data from 210,260 TRA and 229,687 transfemoral access procedures were analyzed. Following multivariate analysis, TRA was independently associated with a reduction in bleeding in all presenting syndromes (stable odds ratio [OR]: 0.24, p < 0.001; NSTEACS OR: 0.35, p < 0.001; STEACS OR: 0.47, p < 0.001) as well as access site complications (stable OR: 0.21, p < 0.001; NSTEACS OR: 0.19; STEACS OR: 0.16, p < 0.001). TRA was associated with reduced major adverse cardiac events only in patients with unstable syndromes (stable OR: 1.08, p = 0.25; NSTEACS OR: 0.72, p < 0.001; STEACS OR: 0.70, p < 0.001). TRA was associated with improved outcomes compared with a transfemoral access (TFA) with a vascular closure device in a propensity matched cohort.
  
  
  CONCLUSIONS
  In this large study, TRA is associated with reduced percutaneous coronary intervention-related complications in all patient groups and may reduce major adverse cardiac events and mortality in ACS patients. TRA is superior to transfemoral access with closure devices. Use of TRA may lead to important patient benefits in routine practice. TRA should be considered the preferred access site for percutaneous coronary intervention.
authors.affiliation: Department of Cardiology, University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom.
authors.forename: Karim
authors.initials: K
authors.lastname: Ratib
authors.affiliation: Manchester Heart Centre, United Kingdom; University of Manchester, Manchester, United Kingdom.
authors.forename: Mamas A
authors.initials: MA
authors.lastname: Mamas
authors.affiliation: University of Manchester, Manchester, United Kingdom.
authors.forename: Simon G
authors.initials: SG
authors.lastname: Anderson
authors.affiliation: Heart of England National Health Service Trust, west Midlands, United Kingdom.
authors.forename: Gurbir
authors.initials: G
authors.lastname: Bhatia
authors.affiliation: Worcestershire Royal Hospital, Worcestershire, United Kingdom.
authors.forename: Helen
authors.initials: H
authors.lastname: Routledge
authors.affiliation: James Cook University Hospital, Middlesbrough, United Kingdom.
authors.forename: Mark
authors.initials: M
authors.lastname: De Belder
authors.affiliation: University Hospital Birmingham, Birmingham, United Kingdom.
authors.forename: Peter F
authors.initials: PF
authors.lastname: Ludman
authors.affiliation: Manchester Heart Centre, United Kingdom.
authors.forename: Douglas
authors.initials: D
authors.lastname: Fraser
authors.affiliation: Department of Cardiology, University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom. Electronic address: nolanjim@hotmail.com.
authors.forename: James
authors.initials: J
authors.lastname: Nolan
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016009:Chi-Square Distribution; D016208:Databases, Factual; D005263:Femoral Artery; D006470:Hemorrhage / Q000209:etiology / Q000401:mortality / Q000628:therapy; D006489:Hemostatic Techniques / Q000295:instrumentation; D006801:Humans; D016015:Logistic Models; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D010818:Practice Patterns, Physicians'; D017064:Process Assessment, Health Care; D057216:Propensity Score; D017534:Radial Artery; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom; D065506:Vascular Closure Devices
keywords: access site; acute coronary syndromes; femoral; outcomes; percutaneous coronary intervention; radial