Interventional cardiology

Jury is in for ‘radial first’ approach for coronary interventions

Radial artery access for coronary angiography or PCI is associated with lower risks of all-cause death and bleeding compared with femoral access, an Italian study has confirmed.

Thirty years after the first radial access interventional coronary procedure was performed, researchers have told the ESC Congress 2022 that they have finally obtained robust evidence from high-quality randomised trials to show that the use of a transradial approach (TRA) instead of transfemoral approach (TFA) is associated with reduced all-cause mortality.

While some studies have previously shown that TRA is associated with a mortality benefit, none were adequately powered for individual endpoints including mortality, said study author Dr Giuseppe Gargiulo of Federico II University Hospital, Naples.

Investigators from the Radial Trialists’ Collaboration (RTC) therefore obtained individual patient data from trials comparing TRA versus TFA among participants undergoing coronary angiography with or without PCI.

Their meta-analysis included pooled data from seven trials with a total of 21,600 patients, of which 10,775 were randomised to TRA and 10,825 were randomised to TFA. The median age of participants was 63.9 years, 31.9% were women, 95% presented with acute coronary syndrome, and 75.2% underwent PCI.

The primary outcome was all-cause mortality at 30 days and the co-primary outcome was major bleeding at 30 days.

Based on the intention-to-treat cohort, the incidence of all-cause death was 1.6% in the TRA group and 2.1% in the TFA group, for a hazard ratio of 0.77 (95% confidence interval [CI] 0.63–0.95; p=0.012).

Major bleeding was also significantly reduced with TRA versus TFA, occurring at rates of 1.5% and 2.7%, respectively, for an odds ratio of 0.55 (95% CI 0.45–0.67; p<0.001).

“The benefit accrues early (i.e. within 10 days) after PCI and is maintained up to 30-day follow-up,” said Dr Gargiulo.

The survival benefit was confirmed in the per-protocol, as-treated, PCI, acute coronary syndrome, and myocardial infarction cohorts. The effects of TRA were also consistent across the majority of pre-specified subgroups, and the findings indicated that patients with baseline anaemia might have a greater mortality benefit compared to those without anaemia.

According to the study investigators, TRA was independently associated with a significant 24% relative risk reduction of 30-day all-cause mortality and 51% reduction of major bleeding in a multivariate model. Further analysis showed that the benefit of TRA on mortality was only marginally driven by the prevention of major bleeding.

“Our study conclusively indicates a favourable prognostic impact of TRA over TFA in terms of survival,” said Dr. Gargiulo.

“It should be noted that the advantages of TRA for mortality, major bleeding and other clinical outcomes primarily apply to acute coronary syndrome patients, who represented approximately 95% of our study population, and cannot be fully extended to elective patients undergoing coronary angiography with or without PCI,” he added.

“This analysis provides definitive evidence that TRA should be considered the gold standard for patients undergoing cardiac catheterisation with or without PCI, supporting the ‘radial first’ approach,” he concluded.

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