Radial Access for PCI Seems to Cut Contrast-Nephropathy Risk

Marlene Busko

April 12, 2016

CHICAGO, IL — Radial-access PCI was associated with a lower incidence of contrast-induced nephropathy than femoral-access PCI, in a large retrospective, single-center study that adds to previous registry findings[1]. The finding was independent of volume of contrast agent used and some other possible confounders.

A father-and-daughter team, Dr Samir B Pancholy (Wright Center for Graduate Medical Education, Commonwealth Medical College, Scranton, PA) and medical student Maitri S Pancholy (Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA), presented these findings in a poster session at the American College of Cardiology (ACC) 2016 Scientific Sessions.

The decreased risk of bleeding with radial access is likely driving the reduced risk of contrast-induced nephropathy, Samir Pancholy told heartwire from Medscape. With femoral access, "when we stick the groin, we have a higher chance of having a major bleeding event," he noted.

"It's another example of the overall benefits of radial access—the decrease in bleeding that this does allow to happen definitely benefits the patient's outcome," according to Maitri Pancholy.

Not involved in the study, Dr Jonathan Bier (Hawthorn Medical Associates, Dartmouth, MA) commented that despite these findings, other patient factors play a larger role in determining the type of access he uses for a particular patient. "I would not use my concern about contrast-induced nephropathy to guide my [decision about] access point," he said. Since 2007, the study start, clinicians have improved how both types of procedures are done, he observed.

"Dr Pancholy is a pioneer in transradial access," Dr Thomas A Haldis (Sanford Health, Fargo, ND), who also stopped to look at the poster, commented. "I use his technique of hemostasis without total occlusion for all my patients at Stanford," he added. "So once again the Pancholy family has led the way with another important study looking at the benefits of radial access in patients undergoing percutaneous intervention, and essentially this is just new data showing that contrast-induced nephropathy can be reduced by using an access site that reduces your bleeding complications."

Does Access Site Predict Kidney Injury?

Contrast-induced nephropathy after angiography increases morbidity, mortality, and cost of care, the researchers note.

Moreover, studies from the British Columbia Cardiac and Renal Registry have reported that patients who have femoral-access PCI have a fourfold higher risk of kidney injury than patients who have radial-access PCI. Other studies from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium have shown that radial access reduced the risk of contrast-induced nephropathy in PCI. However, the studies did not use a consistent definition of kidney injury.

To investigate this relationship, the researchers analyzed data from 5353 patients who had femoral-access PCI and 2176 patients who had radial-access PCI at a tertiary-care center in Pennsylvania from 2007 to 2014.

Contrast-induced nephropathy was defined as serum creatinine that increased by >25% or by >0.5 mg/dL from baseline to 48 to 72 hours after the PCI procedure.

The patients who had radial- vs femoral-access PCI were younger (mean age 62 vs 65) and more likely to be male (70% vs 67.1%) or have hypertension (74% vs 71%), but they were also less likely to smoke (36% vs 52%) or have hyperlipidemia (72% vs 78%) or previous CABG (7% vs 18%) (all significant).

Moreover, the patients who had radial-access PCI vs femoral access PCI had procedures that used less contrast volume (190 mL vs 220 mL), and they were less likely to have Mehran score >11 (7.2% vs 11.4%) or a Bleeding Academic Research Consortium (BARC) bleeding score of 3 to 5 (1% vs 5%) or to need a blood transfusion (0% vs 3%) (all significant).

Access Site, BARC Bleeding, and Mehran Score

A total of 1.1% of the patients in the radial-access group and 2.4% of the patients in the femoral-access group developed contrast-induced nephropathy (P=0.001).

This complication was significantly more likely in patients who were older (mean age 69 vs 64), had diabetes (50% vs 32%), previous stroke (21% vs 10%), CHF (25% vs 9%), peripheral artery disease (19% vs 12%), cardiogenic shock (17% vs 2%), a higher baseline creatinine (1.3 mg/dL vs 0.9 mg/dL), and ACS (82% vs 76%).

Contrast-induced nephropathy was also significantly more likely in patients with BARC bleeding 3 to 5 (11% vs 3%) or Mehran score >11 (47% vs 9.4%) or those who had a transfusion (7% vs 2%) or had access-site complications (5% vs 2%).

Access site, BARC bleeding, and Mehran score independently predicted contrast-induced nephropathy.

Independent Predictors of Contrast-Induced Nephropathy

Factor OR (95%CI) P
Mehran score >11 1.23 (1.19–1.27) 0.0001
BARC 3 or 5 bleed 1.65 (1.17–3.66) 0.0132
Radial access site 0.60 (0.39–0.96) 0.033

After correction for multiple variables including BARC 3 bleeding complications and contrast volume, transfemoral access was independently associated with likelihood of contrast-induced nephropathy (odds ratio 1.7, 95% CI 1.1–2.8; P=0.03).

Samir Pancholy is a consultant for Terumo. Maitri Pancholy has no relevant financial relationships. Disclosures for the coauthors are listed in the abstract.

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