Breaking News
December 18, 2018 - Weight change in middle-aged, elderly Chinese Singaporeans related to increased risk of death
December 18, 2018 - Immune cells sacrifice themselves to protect us from invading bacteria
December 18, 2018 - Watching brain cells fire, with a twist of gravitational waves
December 18, 2018 - 2018 in Review
December 18, 2018 - Getting the Most Out of the CLARITY Technique
December 18, 2018 - NVF shoes provide a viable option for track and road racing
December 18, 2018 - CRISPR may restore effectiveness of chemotherapies used to treat lung cancer
December 18, 2018 - New app accurately measures and charts progression of skin wounds
December 18, 2018 - Persistent Discrimination ID’d Among Physician Mothers
December 18, 2018 - Cellphone technology developed to detect HIV
December 18, 2018 - A Stanford doctor hits the field with the 49ers — as their airway management physician
December 18, 2018 - The Rise of Anxiety Baking
December 18, 2018 - Just one night of sleep deprivation increases the urge to eat
December 18, 2018 - Study reveals mechanism behind failed remyelination in MS
December 18, 2018 - New genetic testing method increases the precision of biomarker analysis
December 18, 2018 - Simple technique to effectively treat underdiagnosed cause of debilitating chest pain
December 18, 2018 - Barbershop-based medical intervention can successfully lower blood pressure, new data shows
December 18, 2018 - Food labels have caused changes in consumers’ intake and industry’s use of key additives
December 18, 2018 - Sickest children could benefit from split liver transplants
December 18, 2018 - Scientists create patient-specific model to identify most effective treatment for appendix cancer
December 18, 2018 - Researchers discover promising new compound against Buruli ulcer
December 18, 2018 - Study finds significant use of traditional, complementary and alternative medicines in Sub-Saharan Africa
December 18, 2018 - California Farm Implicated in Outbreak of E. coli Tied to Romaine Lettuce
December 18, 2018 - Mobile health has power to transform HIV/AIDS nursing
December 18, 2018 - Celiac Vaccine in Clinical Trials at Columbia
December 18, 2018 - Research into mental health first aid prompts practical guidance and resources for workplace
December 18, 2018 - Researcher conducts study to investigate peripheral blood markers of Alzheimer’s disease
December 18, 2018 - Researchers identify link between mucus in the small airways and pulmonary fibrosis
December 18, 2018 - EU Commission’s Health Policy Platform to host EKHA program on transplantation
December 18, 2018 - Survivors of childhood Hodgkin lymphoma have high risk of developing solid tumors
December 18, 2018 - Small changes to cafeteria design can get kids to eat healthier, new assessment tool finds
December 18, 2018 - From Machines to Cyclic Compounds
December 18, 2018 - New study reveals best assessment tools to establish delirium severity
December 18, 2018 - Rice University scientists develop synthetic protein switches to control electron flow
December 18, 2018 - Home-based pulmonary function monitoring for teens with Duchenne muscular dystrophy
December 18, 2018 - Researchers identify potential target for new breast cancer treatments
December 18, 2018 - National Biofilms Innovation Centre award grant to Neem Biotech for novel anti-biofilm drug development
December 18, 2018 - Artificial intelligence and the future of medicine
December 18, 2018 - Montana State doctoral student receives grant for her work to improve neuroscience tool
December 18, 2018 - Early postpartum initiation of opioids associated with persistent use
December 18, 2018 - Russian scientists identify molecular ‘switch’ that could be target for treatment of allergic asthma
December 18, 2018 - Surgeons make more mistakes in the operating room during stressful moments, shows study
December 18, 2018 - Immune cells explode themselves to inform about the danger of invading bacteria
December 18, 2018 - Malnutrition in children with Crohn’s disease linked with increased risk of surgical complications
December 18, 2018 - FDA Approves Motegrity (prucalopride) for Adults with Chronic Idiopathic Constipation (CIC)
December 18, 2018 - The long and short of CDK12
December 18, 2018 - Hologic’s Cynosure division introduces TempSure Surgical RF technology in North America
December 18, 2018 - CMR Surgical partners with Nicholson Center to launch U.S.-based training program for Versius
December 18, 2018 - Findings reinforce guidelines for cautious use of antipsychotics in younger populations
December 18, 2018 - Study finds new strains of hepatitis C virus in sub-Saharan Africa
December 18, 2018 - New battery-free, implantable device aids weight loss
December 18, 2018 - Parental alcohol use disorder associated with offspring marital outcomes
December 18, 2018 - Novel Breast Imaging Technique Might Cut Unnecessary Biopsies
December 18, 2018 - What can a snowflake teach us about how cancer spreads in the body?
December 18, 2018 - Management of nausea and vomiting in pregnancy costs the NHS more than previously thought
December 18, 2018 - Green leafy vegetables may reduce risk of developing liver steatosis
December 18, 2018 - Veganism linked to nutrient deficiencies and malnutrition if not planned correctly
December 18, 2018 - Coming Soon: A Tiny Robot You Swallow to Help You Stay Healthy
December 18, 2018 - Modified malaria drug proven effective at inhibiting Ebola
December 18, 2018 - Study finds epigenetic differences in the brains of individuals with schizophrenia
December 18, 2018 - Fitness instructors’ motivational comments influence women’s body satisfaction
December 18, 2018 - Study focuses on modification of lipid nanoparticles for successful brain cell targeting
December 18, 2018 - New gut bacteria may be effective against obesity, metabolic and mental disorders
December 18, 2018 - New two-in-one powder aerosol to upgrade fight against deadly superbugs in lungs
December 18, 2018 - Biofilms feed with swirling flows
December 17, 2018 - Study identifies specific neurological changes related to traumatic brain injury
December 17, 2018 - New study confirms geographic bias in lung allocation for transplant
December 17, 2018 - Research focuses on optimization of solid lipid nanoparticle that encapsulates Vinorelbine bitartrate
December 17, 2018 - Carpal tunnel syndrome – Genetics Home Reference
December 17, 2018 - A novel insulin accelerant
December 17, 2018 - Tips for caring for patients with disabilities, from a mother and physician
December 17, 2018 - Menopause-related sexual, urinary problems tied to worse quality of life
December 17, 2018 - In-school nutrition programs among students limit increases in BMI, finds study
December 17, 2018 - Risk for Hospitalization for Heart Failure Greater With Diabetes
December 17, 2018 - Food assistance may help older adults adhere to diabetes meds
December 17, 2018 - Supporting a family’s goals during a difficult pregnancy
December 17, 2018 - Neurons with Good Housekeeping Are Protected from Alzheimer’s
December 17, 2018 - New approach to tumor analysis could improve prognosis for bowel cancer patients
December 17, 2018 - New ‘epigenetics-based’ cervical cancer test outperforms Pap smear and HPV tests
December 17, 2018 - Ten year follow-up after negative colonoscopy related to reduced risk of colorectal cancer
Study: Transfemoral Access for PCI Far from Perfect

Study: Transfemoral Access for PCI Far from Perfect

image_pdfDownload PDFimage_print

Action Points

  • There are important gaps between current practice and best practices and guideline-directed techniques for femoral artery access for coronary angiography and percutaneous coronary intervention (PCI), according to a multinational survey.
  • Transradial access (TRA) is associated with decreased odds of bleeding complications, mortality, and major adverse cardiac events (MACE) in patients undergoing PCI following thrombolysis for ST-segment elevation MI (STEMI), according to a U.K. dataset.

Many operators have plenty of room to improve with the transfemoral approach, which is still the predominant access site for coronary angiography and percutaneous coronary intervention (PCI), a study suggested, while a separate analysis showed for the umpteenth time the superiority of transradial access.

In a survey, 60% of operators said they preferred to get access using femoral pulse palpation alone. Another 11% used fluoroscopy guidance and 27% took advantage of a combination of palpation, fluoroscopy, and ultrasound, according to the results of the i-FACTS survey by Mauricio Cohen, MD, of University of Miami Miller School of Medicine, and colleagues, writing online in JACC: Cardiovascular Interventions.

Femoral angiography was also not used consistently despite guideline recommendations: 23% of operators performed it immediately after access, 47% at the end of the procedure; and 31% just didn’t do it at all.

“This study highlights the fact that femoral techniques and practices are variable with persistence of techniques known to compromise safety,” the authors wrote. “As such, our study serves the purpose of raising awareness on best practices for femoral access techniques in the catheterization laboratory.”

Cohen’s group got responses from 987 operators around the world. Survey invites were sent via email to over 12,000 interventional cardiologists, yielding a response rate of 8%; a total of 38% of respondents identified as radialists, 18% as femoralists, and 42% as both.

Operators in North America had the lowest proportion of respondents using just palpation for their access (31%); the rest were split between palpation plus fluoroscopy and palpation plus fluoroscopy plus ultrasound use.

The snapshot of global practice appeared to seem worrying for Ian Gilchrist, MD, of Penn State University College of Medicine in Hershey, writing in an accompanying editorial.

“Contrary to the descriptions of optimal femoral access from cardiovascular thought leaders and various society guidelines, the practice of femoral access in the real world appears suboptimal. This is an important study, as it is a canary in the coal mine pointing to a significant unmet need for education in modern femoral artery access techniques, and it provides impetus for quality improvement to improve the use of ultrasound imaging and other techniques to enhance vascular access.”

Gilchrist suggested that the weaknesses of the study — its reliance on email lists and the potential for nonresponder bias — were no small caveats. However, he said: “If anything, the physicians responding to this poll, being internet users, might be more aware of, and biased towards, the current standards in vascular access. Given that the responses were self-reported and not objectively determined, a bias toward ideal practice might also be predicted.”

Meanwhile, transradial access continued to be linked to better outcomes after PCI, this time in the setting of stenting after thrombolysis for ST-segment elevation MI (STEMI), another study found.

From a British Cardiovascular Intervention Society dataset spanning 2007 to 2014, it appeared that going through the wrist, after multivariable adjustment, was associated with lower odds of in-hospital events compared with the alternative of through the thigh:

  • Mortality (OR 0.59, 95% CI 0.42-0.83)
  • Major bleeding (OR 0.45, 95% CI 0.31-0.66)
  • Major adverse cardiac events (MACE; OR 0.72, 95% CI 0.56-0.94)

As shown in the study published in the same issue, Muhammad Rashid, MBBS, of Keele Cardiovascular Research Group in the United Kingdom, and colleagues found reduced 30-day mortality with transradial access as well (OR 0.72, 95% CI 0.55-0.94).

“Patients undergoing PCI following recent thrombolysis are among the highest-risk patient groups of sustaining major bleeding complications and would therefore have the greatest benefit from undergoing PCI through the transradial approach,” the researchers wrote. “Our data are consistent with this and not only show that odds of major bleeding are reduced by 55% associated with the use of transradial access, but also translate into a reduced mortality and MACE [major adverse cardiac events] risk in patients undergoing PCI after thrombolysis.”

Death rates converged by 1 year between groups, however (OR 0.82, 95% CI 0.66-1.02).

The study’s sample of patients (n=10,209) was roughly split between transfemoral and transradial groups. Baseline differences included the presence of more comorbidities among those undergoing transfemoral PCI and more aggressive pharmacotherapy given to the transradial group.

The proportion of patients who got thrombolytic PCI dropped from 38% in 2007 to 1.2% in 2014.

Access through the wrist went from accounting for 36.3% of PCIs after thrombolysis in 2007 to 83.5% in 2014. Over the same time, it grew from 24.6% to 76.6% of primary PCIs.

Rashid’s group acknowledged that in addition to the observational nature, the study suffered from having PCI complications reported by operators (making the complications likely under-reported) and the lack of data on access site crossover.

Nonetheless, the bulk of the literature overwhelmingly supports transradial access, according to Sunil Rao, MD, of Duke Clinical Research Institute, and Surya Dharma, MD, PhD, of the University of Indonesia, writing in an accompanying editorial.

To facilitate the adoption of wrist-based access in the catheterization lab, Rao and Dharma suggested newer techniques such as the use of the anatomical “snuff box” distal radial artery — which allows for a more ergonomically attractive left radial approach — and the development of newer equipment dedicated to transradial access.

Moreover, it is time to give it a boost in guidelines published by professional societies, the editorialists said: “The number of studies showing a consistent benefit of radial access appears to meet criteria for a Class I recommendation at a high level of evidence.”

Cohen disclosed financial relationships with AstraZeneca, Merit Medical, Abiomed, Medtronic, and Terumo Medical.

Dharma, Gilchrist, and Rashid reported no conflicts of interest.

Rao reported a financial relationship with Medtronic.


Tagged with:

About author

Related Articles