Value of Left Radial Access PCI Shines in National Registry

Patrice Wendling

June 12, 2018

A left radial artery approach to percutaneous coronary intervention (PCI) confers no greater risk for complications than right radial access and may be associated with an early stroke benefit, UK national registry data suggest.

Results from more than 300,000 patients show no significant differences between right or left radial access in adjusted rates of in-hospital death, 30-day mortality, major adverse cardiac events (MACE), or major bleeding.

Further, in a propensity score–matching analysis, left radial access (LRA) was associated with a significantly lower in-hospital stroke risk, the researchers report. Their findings were published in JACC Cardiovascular Interventions.

"Because of the anatomical difference in the carotid arch in left and right access, this certainly makes sense that perhaps there is a reduced risk of stroke and reduced risk of embolization of plaque into the carotid artery and into the brain with left radial access," lead author Muhammad Rashid, MBBS, Keele University, Stoke-on-Trent, United Kingdom, told | Medscape Cardiology. "Also, there is less catheter manipulation because the procedure is perhaps more simple and more straightforward if you go left radial."

Right radial access (RRA) is typically the initial access site for PCI because of operator convenience and catheter lab setup, but during RRA the catheter needs to be passed into the ascending aorta where the right carotid comes off. LRA offers more favorable vascular anatomy because the left common carotid artery arises directly from the aortic arch, he said.

In an accompanying editorial, Ferdinand Kiemeneij, MD, PhD, and Ahmed A. Hassan, MD, both from MC Zuiderzee Hospital, Lelystad, the Netherlands, write, "The positive outcome concerning in-hospital stroke incidence is remarkable considering the unfavorable cardiovascular characteristics in the group undergoing LRA."

National Data Lacking

Prior studies comparing left and right radial access, such as the TALENT trial, have produced mixed results in terms of procedural aspects. Most are small, single-center studies, and there are no national data comparing clinical outcomes between the two approaches, Rashid said.

Using the British Cardiovascular Intervention Society registry, investigators examined 342,806 patients with complete data undergoing PCI using radial access between 2007 and 2014, of which 328,495 cases were undertaken via the RRA and 14,311 via the LRA.

At baseline, patients in the LRA group vs those in the RRA group were significantly older (66.2 years vs 63.8 years) and had a significantly higher incidence of diabetes (27.7% vs 18.2%), hypertension (64.8% vs 52.7%), prior cerebrovascular event (7.4% vs 4.0%), prior acute myocardial infarction (MI) (47.6% vs 24.4%), coronary artery bypass grafting (CABG) (33.2% vs 4.9%), and peripheral vascular disease (12.8% vs 4.5%).  

LRA was used more frequently in short-stature patients (<150 cm) than tall patients (6.8% vs 3.4%) and those with a history of CABG vs without (23.4% vs 3.0%) but was used less frequently in patients requiring PCI for ST-segment elevation MI vs elective PCI (1.8% vs 5.5%).

There was a slight uptick in the use of LRA during the study period (3.2% to 4.6%), with the proportion of radial procedures untaken via the LRA varying from highs of 20% in England to 10% in Scotland and 7% in Wales.

In terms of outcomes, the researchers found no significant difference in in-hospital or 30-day mortality, MACE, or major bleeding with use of LRA vs RRA.

Table. Outcomes With LRA vs RRA

Endpoint Odds Ratio (95% Confidence Interval) P Value
In-hospital death 1.19 (0.90 - 1.57) .20
30-day mortality 1.17 (0.93 - 1.74) .16
MACE 1.06 (0.86 - 1.32) .56
Major bleeding 1.22 (0.87 - 1.77) .24

 However, in propensity match analysis, LRA was associated with a significant decrease in in-hospital stroke vs RRA, they report (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.37 - 0.82; P = .005).

Access Site Switch

When the investigators examined patients who underwent multiple PCI procedures, results show that RRA use for the second procedure dropped 28% overall, 35% among women, and 27.4% among those 75 years and older. Rather than turn to the contralateral radial artery, however, 23.5% of patients had their access changed to a femoral approach and only 4.5% to LRA.

"This has shown an area for us to improve on and for our programs to provide training for operators as well as the upcoming interventional cardiologists to think about using the contralateral arm instead of just going to the femoral access," Rashid said.

"If you can't do the procedure from the right for whatever reason, if the right radial artery is occluded or there are tortuosity issues, the left radial artery offers a very safe alternative in terms of better procedural outcomes and, as we have shown in this series for the very first time, it is perhaps associated with a reduced risk of stroke as well," he said.

Independent predictors of LRA use at any time were previous CABG (OR, 9.32), vein graft PCI (OR, 2.10), renal failure (OR, 2.65), mechanical ventilation (OR, 2.61), peripheral vascular disease (OR, 1.81), prior acute MI (OR, 1.29), female sex (OR, 1.27), and repeat PCI (OR, 1.09).

"A disturbing finding is that about one third of patients who had previous PCI via RRA, had a next procedure via femoral approach," especially women and the elderly, write Kiemeneij and Hassan.

The registry, however, lacks data on right radial artery patency and previous diagnostic coronary angiography, they note.

"Such information would provide significant insights regarding the decision of access switch," they write. "If radial artery occlusion was the predominant driver to proceed via femoral approach, this would certainly be a focus for procedural improvement."

The editorialists and Rashid note that operator discomfort and closer proximity to the radiation source are important reasons for RRA preference but suggest that practical solutions may include a left distal radial approach, where the left radial artery is punctured in the anatomic snuffbox, as well as workstation improvements to provide better arm support for operators.

"We know that the debate between radial and femoral is pretty much a settled one," Rashid said. "There is an enormous amount of data from randomized studies as well as from observational studies to show that radial is associated with better outcomes, increased patient satisfaction, and decreased health care costs, and so on. I think it's time to move on to looking at the other avenues in order to increase the use of radial access."

The authors and editorialists report having no relevant financial relationships.

JACC Cardiovasc Interven. Published May 16, 2018. Abstract, Editorial

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