News Release

Radial and femoral access for coronary angiography yield similar results in large multicentre trial

Peer-Reviewed Publication

The Lancet_DELETED

Previous small trials have been unable to establish a clinical advantage between coronary angiography via the femoral artery in the groin or the radial artery in the wrist, and there remains considerable disagreement amongst cardiologists about the best approach. A study to be published Online First in The Lancet to coincide with its presentation at the American Society of Cardiology meeting in New Orleans, reports that radial access for coronary angioplasty in patients with acute coronary syndromes (ACS) does not reduce death, heart attack, stroke, or major bleeding compared with femoral access. However, the significantly lower rate of complications at the access site and improved patient comfort might be a reason to use the radial approach.

In patients with ACS, coronary angiography is used to see blocked arteries in the heart. During the procedure a catheter is threaded through a femoral or radial artery and into the blood vessels supplying the muscle of the heart. Dye is injected to allow any narrowing or blockage to be visible on X-ray. A percutaneous coronary intervention (PCI), such as balloon angioplasty or stent placement, is then performed as needed to unblock the blood vessels. Previous small trials have suggested that radial access might result in less bleeding and reduce vascular complications compared with femoral access.

To provide more evidence, an international team led by Sanjit Jolly from the Hamilton General Hospital, Hamilton, Canada established a large, multicentre trial to assess whether radial access was superior to femoral access in patients with ACS (a heart attack with visible changes on the electrocardiogram called ST-elevated myocardial infarction [STEMI], non-STEMI heart attack, or unstable angina) undergoing coronary angiography with possible intervention.

Between June 2006 and November 2010, 7021 patients from 158 hospitals in 32 countries were enrolled and randomly assigned to radial (3507 patients) or femoral access (3514).

Findings showed that the combined endpoint (death, heart attack, stroke, or major bleeding at 30 days) was nearly identical in the two groups, occurring in 128 (3.7%) of patients in the radial access group and 139 (4.0%) in the femoral access group.

However, significantly lower complications were recorded at the access site with radial compared with femoral access.

At 30 days, more patients in the femoral group had large haematoma (106 vs 42) and pseudoaneurysm needing closure (23 vs 7). Importantly, in patients with STEMI, radial access seemed to reduce major adverse events and death and also appeared beneficial compared with femoral access in centres undertaking a high number of radial procedures.

The authors conclude: "In patients with ACS undergoing coronary angiography, radial access did not reduce the primary outcome of death, myocardial infarction, stroke or, non-coronary artery bypass graft (non-CABG)-related major bleeding compared with femoral access. However, radial access significantly reduced vascular access complications compared with femoral access, with similar PCI success rates, and was commonly preferred by patients for subsequent procedures."

In a Comment, Carlo di Mario and Nicola Viceconte from the Royal Brompton Hospital, London, UK say: "After this study, there is little justification to ignore one of the main developments in interventional cardiology and stubbornly refuse to embrace a technique likely to reduce minor adverse events (but in patients with STEMI, possibly also major adverse events and mortality) and improve patient comfort."

He adds: "Operators with a high workload of acute procedures should seriously consider re-training in radial angioplasty, and all new trainees should be taught and become proficient with this approach. Conversely, it is important not to demonise the femoral approach, which is more suitable when large guiding catheters are required and prolonged procedural time is expected for complex lesions."

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