Signal that left radial access reduces the risk of PCI-related stroke

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Muhammad Rashid

A new study shows that patients who undergo percutaneous coronary intervention (PCI) via left radial access have a similar risk of in-hospital/30-day mortality, major adverse cardiovascular events (MACE) or major complications as those who undergo PCI via right radial access. However, it also indicates that left radial access patients may have a lower risk of PCI-related stroke.

Muhammad Rashid (Keele Cardiovascular Research Group, Keele University, Stroke-on-Trent, UK) and others report in JACC: Cardiovascular Interventions that left radial access offers “much more favourable vascular anatomy” than right radial access “particularly in short stature patients or those with previous coronary artery bypass grafts, resulting in less catheter manipulation and a theoretically smaller risk of procedure-related stroke”. However, they note that data for right radial access vs. left radial access have produced conflicting results.

According to the authors, understanding how left radial access compares with right radial access will become more important in the future because “as the population requiring PCI grows and ages, it is likely that left radial access will become more commonplace”. Therefore, to provide further information in this area, Rashid et al reviewed data from the British Cardiovascular Intervention Society (BCIS) registry to compare outcomes of patients who had undergone PCI with left radial access with those who underwent PCI with right radial access. The primary endpoints were in-hospital mortality and 30-day mortality, in-hospital major bleeding, in-hospital MACE, and in-hospital stoke.

Of 343, 725 patients who underwent the PCI with the transradial approach between 2007 and 2014, 96% underwent the transradial approach via right radial access and 4% underwent it via left radial access. However, use of left radial access increased over time—from 3.2% in 2007 to 4.6% in 2014. Stepwise multivariable analysis showed that the independent predictors of left radial access being used were previous coronary artery bypass grafting (CABG), PCI to vein graft, renal failure, peripheral vascular disease, previous acute myocardial infarction, female sex, and repeat PCI procedure.  Additionally, left radial access PCI was undertaken in Asians far more than in Caucasians—27.9% vs. 4.2%.

A multivariable logistic regression found there were no significant differences in the rate of in-hospital death, 30-day mortality, and in-hospital stroke between patients who underwent PCI via left radial access vs. those who underwent PCI via right radial access. However, Rashid et al report: “Notably, in our propensity score matching analysis, left radial access was associated with a significant decrease in in-hospital stroke (p=0.0005).” They comment that anatomical differences between the right radial artery and the left radial artery may explain this apparent reduction in stroke. “With right radial access, the anatomical variations such as increased incidence of tortuosity and loops in arm and subclavian artery may require extra catheter manipulation. Additionally, during right radial access, the catheter needs to be passed from the innominate artery into the ascending aorta where the right carotid artery comes off resulting in a theoretically increased risk of embolisation of plaque into the right carotid artery resulting in embolic stroke,” the authors explain.

Although the rate of in-hospital stroke did appear to be lower with left radial access, overall, the in-hospital stroke event rate was low. Thus, Rashid et al observe: “Given low event rates, it is unlikely that a randomised controlled trial will ever be adequately powered to investigate this further.”

They conclude: “Left radial access provides a safe and effective alternative access site choice compared to right radial access,” noting that “future efforts need to focus around education and training to preserve radial artery patency and increase skills in the use of left radial access”.

Rashid told Cardiovascular News: “Left radial artery is a safe alternative access site, particularly for right-handed patients undergoing PCI procedures.”

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