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Radial PCI and the obesity paradox: Insights from Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2)
Jonathan R McDonagh1, Milan Seth2, Thomas A LaLonde3
1Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, Michigan.
Insights
Transradial approach (TRA) reduces bleeding and transfusion needs in percutaneous coronary intervention (PCI) patients. This benefit is most significant for lean and morbidly obese individuals, offering a safer alternative to femoral access.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Vascular Access
Background:
- Patients with extreme body mass indices (BMIs) face elevated bleeding risks post-percutaneous coronary intervention (PCI).
- Transradial approach (TRA) is increasingly recognized for its potential to lower bleeding complications compared to the traditional femoral approach.
Purpose of the Study:
- To determine if transradial approach (TRA) mitigates the heightened bleeding risk associated with femoral access in percutaneous coronary intervention (PCI).
- To specifically evaluate the safety and efficacy of TRA versus femoral access in lean (BMI < 25 kg/m²) and morbidly obese (BMI ≥ 40 kg/m²) patient populations.
Main Methods:
- A retrospective analysis of PCI procedures performed between 2010 and 2012 was conducted using data from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium PCI registry.
- Propensity matching (PM) was employed to adjust for the non-randomized utilization of TRA, comparing outcomes between TRA and femoral access groups.
- Primary outcomes assessed included incidences of bleeding and the need for post-procedure blood transfusions.
Main Results:
- Transradial approach (TRA) was associated with a significant reduction in bleeding (0.80% vs. 1.9%) and transfusion rates (1.4% vs. 2.5%) compared to femoral access across all patients undergoing PCI.
- The absolute reduction in bleeding and transfusion rates with TRA was most pronounced in patients at the extremes of BMI: lean individuals and those who are morbidly obese.
- Specifically, lean patients showed a bleeding rate of 1.2% with TRA versus 2.8% with femoral access, while morbidly obese patients had a bleeding rate of 0.8% with TRA versus 2.4% with femoral access.
Conclusions:
- Transradial approach (TRA) offers a significant reduction in bleeding complications for patients undergoing percutaneous coronary intervention (PCI) compared to the femoral approach.
- The safety benefits of TRA are particularly pronounced in patient populations with very low (lean) or very high (morbidly obese) body mass indices.
- TRA represents a valuable alternative access site, potentially improving safety profiles for high-risk patient groups undergoing PCI.
Objective:
To examine if transradial approach (TRA) negates the increased risk associated with femoral access in lean and morbidly obese patients undergoing percutaneous coronary intervention (PCI).
Background:
Patients at extremes of body mass are at increased risk of bleeding after PCI. TRA has been associated with lower overall rates of bleeding compared to femoral approach.
Methods And Results:
We studied patients undergoing emergent and elective PCI from 2010 to 2012 across 47 hospitals in Michigan who participate in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium PCI registry. The primary outcomes were the incidences of bleeding and postprocedure transfusion. Propensity matching (PM) was used to adjust for nonrandomized use of TRA. TRA was used in 10,235 procedures. In PM analyses, use of TRA was associated with a reduction in bleeding (0.80 vs. 1.9%, odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.32-0.54, P < 0.001) and need for transfusion (1.4 vs. 2.5%, OR = 0.56, 95% CI = 0.45-0.69, P < 0.001) compared with femoral access. The absolute difference in bleeding and transfusion associated with TRA was largest in patients with lean body mass (BMI < 25 kg/m(2)) and morbid obesity (BMI ≥ 40 kg/m(2)): Lean patients undergoing TRA had a rate of bleeding of 1.2 versus 2.8% for femoral access (OR = 0.43, 95% CI = 0.24-0.77, P = 0.002); and rate of transfusion of 2.4 versus 3.9% (OR = 0.61, 95% CI = 0.40-0.94, P = 0.019). The morbidly obese had a rate of bleeding of 0.8% for TRA versus 2.4% for femoral access (OR = 0.33, 95% CI = 0.44-0.72, P = 0.004); and rate of transfusion of 1.7 versus 3.0%, (OR = 0.55, 95% CI = 0.30-1.0, P = 0.051).
Conclusions:
Compared with the femoral approach, TRA is associated with a reduction in bleeding across all patients undergoing PCI and the absolute benefit was greatest in those with extremely low or high BMI.