Transradial access to heart surgery saves lives in most definitive study

BARCELONA – For coronary angiography with or without percutaneous coronary intervention (PCI), radial access is superior to femoral access, according to a Radial meta-analysis​​​ Bleeding was reduced, and mortality trial collaboration was reduced.

Transradial surgery was associated with lower 30-day all-cause mortality compared with transfemoral surgery (1.6% vs 2.1%, adjusted HR 0.76, 95% CI 0.61 -0.94 ) and major bleeding (1.5% vs 2.7%, adjusted HR 0.49, 95% CI 0.39-0.60), reports Giuseppe Gargiulo, MD, University of Federico II, Naples, Italy.

His team analyzed seven higher-quality multicenter randomized trials that provided individual-level data on 21,600 patients with suspected or confirmed coronary artery disease. This meta-analysis was presented at the European Society of Cardiology (ESC) Congress and concurrently published in Circulation.

European and US guidelines The radial priority strategy for coronary intervention has been endorsed because of its relative safety.

“Now we have clear data that transradial access reduces mortality,” Gargiulo emphasizes.

He noted that the survival benefit associated with radial access was seen in those with severe anemia, but not in those with mild or no baseline anemia.

“Whether TRA [transradial access] is superior to TFA [transfemoral access] in a relatively low-risk study cohort in a subgroup of patients with mild or no anemia The statistically significant prognostic advantage of , reflects a power issue that requires further analysis,” the authors wrote.

They caution that clinicians should not prioritize transradial access only in patients with documented baseline anemia, “especially when allies consider the possibility of choosing a site of access in an emergency. Not knowing this information, and the reduction in major bleeding…regardless of baseline hemoglobin, was very significant and largely consistent throughout the analysis.”

Mount Sinai, NYC ESC conference discussant Gregg Stone, MD, of the Canton School of Medicine also identified ST-segment elevation myocardial infarction (STEMI) patients and operators with extensive radial artery experience as the treatment group with radial access having the greatest impact on survival.

“These data strongly support radial artery intervention in these circumstances, but provide some reassurance (for major femoral operators, or when TRA is difficult) that mortality may not be In patients with STEMI or severe anemia, TFA did not increase and the risk of bleeding was reduced with bivalirudin [Angiomax],” Stone said.

Of note, the most common complication of this approach, radial artery occlusion, may limit future percutaneous procedures and use of the artery as a catheter for coronary artery bypass grafting .

For the radial trialist collaboration meta-analysis, the primary outcome was based on an intention-to-treat analysis. Findings were consistent on a per-protocol basis. Participating operators in the seven included trials had experience with both approaches.

The median age of the large patient cohort was 64 years, and 32% were women. The vast majority of people develop acute coronary syndrome.

About three-quarters underwent PCI, and the rest underwent coronary angiography only.

Incidence of myocardial infarction, stroke, and stent thrombosis was not affected by choice of access site.

The difference in mortality between radial and femoral access appears to be only partially affected by the prevention of major bleeding. Mechanisms related to accessory pathways unrelated to bleeding must therefore play a role in survival, Gargiulo said.

In a news release, he suggested a possible link between reduced acute kidney injury and better patient survival after transradial surgery. However, he cautioned that this assumption goes beyond the scope of existing data.

Stone noted the lack of 1-year data from these trials, noting that “it may take time for the bleeding effect to translate into a mortality benefit.”

Gargiulo and Colleagues also acknowledged that their meta-analysis was limited by each trial included. There was also some heterogeneity in antithrombotic therapy and devices used, clinical presentation, and the definition and management of bleeding across all trials.