In Elderly or Not, Transradial PCI Bests Transfemoral PCI in UK Analysis

Pam Harrison

February 20, 2015

MANCHESTER, UK — Performance of PCI via the transradial route was independently associated with reduced risk of major acute coronary events (MACE), 30-day mortality, and major bleeding outcomes across all age groups, compared with transfemoral procedures, in an analysis based on a large cohort of patients in the UK[1].

"Data derived from randomized controlled trials [and] national UK and US registries have consistently shown reduced risk of access-site bleeding complications and mortality/MACE rates in selected patient subgroups undergoing [transradial] PCI, particularly primary PCI and those patients at high risk of bleeding complications," senior author Dr Mamas A Mamas (University of Manchester, UK) told heartwire by email.

But those studies didn't necessarily include lots of very old patients. So given the current findings, he said, "I think that the lower mortality associated with transradial-access use as well as overwhelming patient preference [for it] would support [the idea that] transradial access should be considered the default access site for PCI irrespective of patient age."

Dr Sanjit Jolly (McMaster University, ON), who was not involved in the current study, agreed: "In physicians with expertise, we should strive to offer the radial approach to both the young and the elderly undergoing PCI."

The new analysis, from Dr Simon G Anderson (University of Manchester) and colleagues, was published online on February 11, 2015 in Catheterization and Cardiovascular Interventions.

The British Cardiovascular Intervention Society collects PCI data relating to the nationwide practice of PCI in the UK. Investigators used this database to study access-site practice in 469 983 patients who underwent PCI procedures in the UK between January 2006 and December 2012.

Patients who underwent PCI through the left or right femoral artery or the left or right radial artery were included in the femoral and radial cohorts, respectively.

The primary outcomes were 30-day mortality and MACE. MACE was a composite of in-hospital mortality and in-hospital MI or reinfarction, in-hospital revascularization, and cerebrovascular events.

Patients were stratified into four age groups: those <60 years; those between 60 and <70 years, those 70 years of age and <80 years, and those 80 years of age and older.

Regardless of the access site used, unadjusted 30-day mortality and MACE rates were consistently lower in the transradial cohort compared with the transfemoral cohort in each age group studied (P<0.0001 across each age group).

Access site by age group 30-d mortality rates (%) In-hospital MACE rates (%)
Radial access
<60 y 0.60 1.0
>80 y 4.4 3.8
Transfemoral access
<60 y 1.1 1.6
>80 y 6.8 6.0

Following multivariate adjustment, there was a nonsignificant 32% decrease in MACE in those under the age of 60 (odds ratio 0.68, 95% CI 0.60–1.13) associated with transradial use, but statistically significant (P<0.0001) independent decreases associated with the use of transradial access in the three older age groups.

Odds Ratio for MACE in Three Older Age Groups

Age group (y) MACE OR (95% CI)
60 to <70 0.60 (0.53–0.69)
70 to <80 0.64 (0.57–0.70)
> 80 0.61 (0.54–0.68)

"The radial approach is also associated with early patient mobilization and comfort," Mamas observed. "So notwithstanding the mortality benefit seen in adoption of transradial access as the default access site, patients prefer transradial access due to improved comfort and earlier mobilization following PCI procedures."

Transradial Access Rules in the UK

According to Jolly, the study shows there have been marked increases in the use of radial access in the UK, such that now transradial access is used in the majority of procedures.

Although use of the radial approach was still lower in the elderly than in younger patients over time, "this is likely explained by the fact that radial access is technically more difficult to perform in elderly patients due to subclavian tortuosity and calcification," Jolly said.

Jolly also noted that during the "learning curve when adopting transradial access," physicians are more likely to choose patients with a higher chance of technical success to start off with. "The counterpoint is that elderly patients have a higher baseline risk of bleeding, so they may particularly benefit from radial access."

Mamas also noted that there is a slightly longer learning curve when adopting transradial access PCI because of the smaller size of the radial artery and the risk of spasm, particularly in the elderly and in female patients. These factors may have also contributed to its slower adoption in these groups, he speculated.

"Paradoxically, those at highest bleeding risk with potentially the greatest benefit were least likely to receive a PCI through the radial approach," Mamas said.

Anderson is funded by the National Institute for Health Research. The coauthors report no relevant financial disclosures.

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