UK Radial-PCI Centers Do Not Have Worse Femoral-PCI Survival

Marlene Busko

September 07, 2016

ROME, ITALY — An analysis of femoral-access PCI procedures performed in England and Wales from 2007 to 2013 found no evidence of worse 30-day survival in centers that had adopted a radial-access PCI approach[1].

That is, there was no sign of a Campeau paradox (named after the Canadian transradial pioneer Lucien Campeau), where operators lose their ability to perform femoral-access PCI when hospitals switch to doing more radial-access PCI.

In unadjusted analysis, 30-day mortality was higher when femoral-access PCI was performed in centers with the highest volume of radial-access procedures. However, the "radial centers" tended to restrict femoral-access for complex, high-risk cases, and after adjustment for this, the relationship between mortality and femoral-access experience disappeared.

Thus, because of the benefits of radial-access PCI, "centers should continue to adopt [it] as the default route for PCI wherever possible," lead author and PhD student Will Hulme (University of Manchester, UK) said at a Young Investigators Awards session at the European Society of Cardiology (ESC) 2016 Congress.

"What they show is you have an increase in the rate of radial [PCI], and the question is, 'Do they continue to have the skills of femoral [PCI]?' and the answer is 'Yes,' because the increase in morbidity and mortality is related to [more complex] pathology and not to decreased skills," Dr Thierry Gilbert (Ghent University, Belgium), one of the judges at the session, told heartwire from Medscape. In other words, sicker patients are more likely to receive femoral access, he said.

A study limitation is that it did not look at bleeding complications, he noted. Nevertheless, the takeaway message for cardiologists is that they will not lose their femoral-approach skills if they begin doing more PCIs using a radial-access approach. However, "to be really good, you should do at least 400 to 800 PCIs a year; that's what the numbers tell," he said.

Two Contradictory Articles

This study was triggered by two apparently contradictory articles that were published within days of each other in late 2015, Hulme explained.

Dr Giuseppe Andò (University of Messina, Italy) and Dr Davide Capodanno (University of Catania, Italy) performed a meta-analysis of four high-quality multicenter trials that compared radial- vs femoral-access PCI in patients with ACS and concluded: "Compared with femoral access, radial access reduces mortality, major adverse cardiovascular events, and major bleeding in patients with ACS"[2].

However, Dr Lorenzo Azzalini (formerly at the Montreal Heart Institute, QC; now at San Raffaele Hospital, Milan, Italy) and colleagues compared a historical cohort of patients who had femoral-access PCI during 1996–1998 vs a contemporary cohort of patients who had either femoral-access or radial-access PCI in 2006–2008 (with 17,059 patients altogether) and came up with a different conclusion: "The safety benefit associated with radial access is offset by a paradoxical increase in vascular-access site complications among femoral access patients"[3].

Meanwhile, in the UK, centers have been rapidly adopting radial access; the proportion of PCI cases that were done using radial access has grown from 10.2% of PCI cases in 2004 to 75.3% of PCI cases in 2014.

Thus, Hulme and colleagues sought to determine whether the Campeau paradox exists in the UK.

Specifically, they aimed to examine whether a center's recent experience (within the past year) with femoral access was associated with 30-day mortality for PCI done using a femoral approach, independent of other risk factors.

They analyzed data from centers as opposed to operators, since the latter data were not collected prior to 2012, Hulme explained.

From the UK PCI registry managed by the British Cardiovascular Intervention Society, the researchers identified 92 centers in England and Wales that performed 235,474 femoral-access PCI procedures from 2007 to 2013.

Individual centers performed less than 25 to more than 200 PCIs a month.

Centers were classed as doing a low, medium, or high proportion (defined as less than a third, a third to two-thirds, and greater than two-thirds) of PCI cases by femoral access in 2013.

During the study period, femoral-access procedures declined and radial-access procedures increased in most centers.

The centers that still performed mainly femoral-access PCI were typically centers that did not perform many PCIs.

In unadjusted analysis, 30-day mortality rates were higher in centers where less than a third of PCI procedures were done using femoral access.

However, patients who underwent PCI that was done using femoral access were usually older and more likely to have cardiogenic shock or need respiratory support or have other complexities, Hulme noted.

Recent performance of a femoral-access PCI procedure made no significant impact on a center's 30-day mortality associated with radial PCI (P=0.220), after adjustment for multiple variables associated with the femoral case, including demographics, clinical indication for PCI, cardiogenic shock, need for circulatory or respiratory support, history of MI or CABG, hypertension, hypercholesterolemia, diabetes, renal function, smoking status, LVEF, type of stent used, number of target coronary vessels, and use of GP IIb/IIIa inhibitors.

Poorer outcomes "are driven by the propensity . . . to utilize femoral access in the highest-risk patients," Hulme and colleagues write. Moreover, after adjustment for case differences, there is "no evidence to suggest that increasing unfamiliarity with the femoral technique is detrimental."

Centers should therefore continue to embrace the radial approach. "The outcome gains achieved by the national adoption of radial access is not attenuated by decreased femoral experience, and centers should be encouraged to continue to adopt radial as the default access site for PCI wherever possible," according to Hulme and colleagues.

The study was funded by the UK Medical Research Council. Hulme has no relevant financial relationships.

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