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Study: Transfemoral Access for PCI Far from Perfect

Study: Transfemoral Access for PCI Far from Perfect

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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.


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