ESC 2022: Transradial access is “gold standard” approach for percutaneous coronary procedures

Giuseppe Gargiulo

Transradial access for percutaneous coronary procedures is associated with lower rates of all-cause mortality and major bleeding at 30 days when compared to transfemoral access.

This was the major finding of a meta-analysis of individual patient data from seven multicentre randomised clinical trials, presented during a hot line session on the final day of the European Society of Cardiology (ESC) 2022 congress (26–29 August, Barcelona, Spain) by Giuseppe Gargiulo (University Federico II of Naples, Naples, Italy). The findings were simultaneously published in the journal Circulation.

The authors of the study—the Radial Trialists’ Collaboration—suggest that the finding of the meta-analysis provides evidence that transradial access should be considered the preferred access-site for percutaneous coronary intervention (PCI) in patients with acute coronary syndrome, supporting recent guideline changes which endorse this approach.

In their paper, the researchers note that there is currently conflicting evidence on whether the radial approach reduces mortality compared with transfemoral access, with some randomised controlled trials finding an association with lower mortality in coronary artery disease patients undergoing invasive management.

In a bid to resolve this question, Gargiulo and colleagues from the Radial Trialists’ Collaboration performed an individual patient data meta-analysis of contemporary randomised trials comparing the two approaches among patients undergoing coronary angiography with or without PCI to assess whether radial access is associated with a lower incidence of mortality and major bleeding. The study team also sought to establish whether these associations are influenced by clinical or procedural characteristics, and if bleeding prevention mediates the mortality reduction.

The meta-analysis included a total of 21,600 patients from across the seven trials, of which 10,775 were randomised to radial access and 10,825 were randomised to femoral access. 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. The primary analysis was conducted based on the intention-to-treat cohort. The incidence of all-cause death was 1.6% in the radial group and 2.1% in the femoral 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 radial versus femoral access, 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 researchers report.

The survival benefit was confirmed in the per-protocol, as-treated, PCI, acute coronary syndrome, and myocardial infarction cohorts. The effects of radial access 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.

In a multivariable model, radial access was independently associated with a significant 24% relative risk reduction of 30-day all-cause mortality and 51% reduction of major bleeding. Mediation analysis showed that the benefit of TRA on mortality was only marginally driven by the prevention of major bleeding.

“Our study provides comprehensive evidence from high-quality multicentre trials that the use of transradial access over transfemoral access is associated with reduced all-cause mortality,” Gargiulo said, summarising the results in a press conference ahead of the full presentation at ESC 2022.

“The meta-analysis provides evidence that transradial access should be considered the gold standard access site for percutaneous coronary procedures, particularly in acute coronary syndromes, supporting [the] most recent recommendations,” Gargiulo concluded.


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