NCDR Study Documents US Radial PCI Gains

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Percutaneous coronary intervention (PCI) via radial access has increased 13-fold in the United States since 2007, according to a study published online June 10, 2013, ahead of print in Circulation. Compared with the transfemoral route, transradial PCI is associated with lower vascular and bleeding complications while maintaining procedural success.

Culling data from the National Cardiovascular Data Registry CathPCI Registry, Dmitriy N. Feldman, MD, of Weill Cornell Medical College (New York, NY), and colleagues looked at over 2.8 million PCI procedures from 1,381 sites between January 2007 and September 2012.

Radial Access Safer

Radial access increased from being used in only 1.2% of procedures in the beginning of 2007 to 16.1% toward the end of 2012 (P < 0.01), equivalent to 6.3% of all procedures (n = 178, 643) over the length of the study period. Notably, however, approximately 13% of sites did not perform any radial PCIs, and only 22 sites performed radial PCI in more than half of cases.

Compared with transfemoral PCI, radial procedures had longer fluoroscopy times (14.2 minutes vs. 11.1 minutes; P < 0.01), but used slightly less contrast (median 178 mL vs. 186 mL; P < 0.01). Radial PCI was more prevalent in university hospitals, in institutions with fellowship/residency programs, and in the Northeast.

Procedural success rates were similar between the 2 approaches, whereas vascular complications (0.16% vs. 0.45%) and bleeding complications (2.67% vs. 6.08%; both P < 0.01) were lower in the radial group.

Multivariate analysis showed that radial procedures were associated with greater procedural success (adjusted OR 1.13; 95% CI 1.06-1.20), fewer vascular complications (adjusted OR 0.39; 95% CI 0.31-0.50), and fewer bleeding complications (adjusted OR 0.51; 95% CI 0.49-0.54). Adjusted outcomes were similar after procedures from sites that performed no radial PCIs were excluded.

Reductions in bleeding and vascular complications with radial PCI were consistent across key subgroups. The greatest absolute gains were seen in patients 75 years and older, females, and those presenting with STEMI. The radial safety advantage was also maintained regardless of hospital PCI volume (above or below 400 procedures per year) or patient BMI (above or below 30).

Look to the High-Risk Patients

In a telephone interview with TCTMD, Dr. Feldman said the increase in radial procedures is not surprising, although the magnitude of it is. He attributes the "steep" rise to more training programs associated with both institutions and professional societies. In addition, he said that he did not expect quite the geographic variability in radial uptake uncovered in the study.

To build upon these data, Dr. Feldman would like to see further randomized data on radial access, especially in a STEMI population. He also recommends studying radial PCI in the elderly and women. "As we accumulate randomized data and the data from studies like ours that support the decrease in bleeding and vascular complications, the procedure will continue to evolve and increase in the United States," he predicted.

The study highlights the fact that radial PCI is underused in patients at high risk for bleeding, the authors write. "This likely reflects concerns over metrics related to rapid reperfusion (door-to-balloon time) that may be adversely affected by radial access," they say. "Indeed, our study, and others, as well, indicates slightly longer procedural times with [radial PCI]. Despite this, if [radial PCI] is shown to reduce mortality from STEMI in an adequately powered randomized trial, wider adoption of transradial primary PCI is warranted."

These patients "can potentially benefit the most from this procedure," Dr. Feldman observed, although he acknowledged that the learning curve for clinicians wishing to treat higher-risk patients radially is substantial. "That’s where we may see more improvement in terms of bleeding and vascular complications in the future," he concluded.

Study Details

Radial PCI procedures were performed more frequently in younger patients, males, and those with a higher BMI. Patients undergoing radial PCI had a lower prevalence of renal insufficiency, peripheral vascular disease, previous MI, congestive heart failure, CABG, or PCI. In addition, radial PCI was more likely to be performed in patients with stable angina and NSTE-ACS than STEMI.

　

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Source:
Feldman DN, Swaminathan RV, Kaltenbach LA, et al. Adoption of radial access and comparison of outcomes to femoral access in percutaneous coronary intervention: An updated report from the National Cardiovascular Data Registry (2007-2012). Circulation. 2013;Epub ahead of print.

Disclosures:

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