Patrice Wendling

May 19, 2017

PARIS, FRANCE — Using transradial rather than transfemoral access during invasive management of patients with acute coronary syndromes significantly reduces the risk of acute kidney injury (AKI), according to a prespecified MATRIX substudy[1].

Radial access reduced the adjusted risk of AKI by 13% (odds ratio 0.87, P=0.018), with the benefit particularly apparent in those at highest risk with stage 3 kidney disease (KDIGO) (OR 0.60, P=0.037).

Radial access should now be added to the five "golden rules" for AKI prevention alongside such known strategies as hydration and discontinuing nephrotoxic drugs, study author Dr Bernardo Cortese (Ospedale Fate bene Fratelli, Milan, Italy) said in presenting the results at EuroPCR 2017.

The caveat, he added, is that "these were very experienced operators in transradial. It is possible that during the initial phases of the learning curve, the first PCIs and angiographies of ACS patients may be associated with a higher use of contrast medium."

There was no difference in the total amount of contrast medium used in the radial vs femoral groups (183.3 vs 183.9, P=0.83), although the results were not adjusted for type of contrast media or hydration.

Data are also being analyzed to determine what impact operator experience may have had on the results, he said.

During a discussion of the data, panel member Dr Jacek Legutko (Jagiellonian University Medical College, Krakow, Poland) agreed radial access should be added as a sixth golden rule for ACS patients but questioned whether this should also be the case for elective or more complex cases such as chronic total occlusion, complex calcified vessels, or multivessel PCI.

"Because there we aren't really sure if the use of the radial approach is the better one, because in those situations the contrast volume is higher," he said.

Cortese responded, "If you are an experienced radial operator you have the feeling, maybe you are wrong, that you can do anything with the radial approach," but "I cannot say from the results of our study that this true for all the transradial approaches, but at least in ACS it is."

Still, Legutko followed by noting that in his native Poland, use of the transradial approach in all comers has shot up over the past 5 years from 40% to 85% in 2016 after the 2015 publication of the initial MATRIX study[2].

It showed a 17% reduction in net clinical adverse events with radial access among 8404 ACS patients, driven by a 33% reduction in major bleeding and 28% reduction in all-cause mortality.

The present Acute Kidney Injury (AKI)-MATRIX substudy, published online in the Journal of the American College of Cardiology, included 4109 patients randomized to radial access and 4101 to femoral access.

The primary outcome of AKI, defined as a >0.5 mg/dL or >25% increase in serum creatinine, occurred in 15.4% of patients in the radial group and 17.4% in the femoral group (P=0.0181). The difference remained significant with either component of the AKI definition.

Postintervention dialysis was numerically lower with radial access than with femoral access (six vs 14 events, P=0.08).

Cortese offered three possible mechanisms for the AKI benefit; the most important, he said, was that radial access compared with femoral access reduces the risk of hemodynamically significant bleeding, which may prevent kidney injury. Radial access is also associated with fewer blood transfusions, which are known to increase AKI.

Third, "It is possible that with the transfemoral approach there is some mobilization of atherosclerotic debris when you cross the renal arteries, so this may lead to some embolization and hamper the functionality of the kidneys," he said.

In an accompanying editorial[3], Drs Sanjit Jolly and Ashraf Alazzoni (McMaster University, Hamilton, ON) write, "This provides another piece of evidence supporting a radial-first approach in patients with acute coronary syndrome who are undergoing coronary angiography or intervention."

The editorialists noted, however, that "despite the benefits observed, the high rates of AKI even in the radial group (15%) suggested that further therapies are needed to prevent AKI."

Cortese reports institutional grant support from AB Medica; honoraria from Hexacath, Amgen, and Stentys; and consulting for Aachen Resonance, Abbott Vascular, AstraZeneca, Kardia, Innova, and Stentys. Disclosures for the coauthors are listed in the paper. Jolly reports grant support from Medtronic and Boston Scientific. Alazzoni reports no relevant financial relationships.

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