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Prediction and impact of failure of transradial approach for primary percutaneous coronary intervention
Eltigani Abdelaal1, Jimmy MacHaalany1, Guillaume Plourde1
1Quebec Heart-Lung Institute, Laval University, Quebec City, Quebec, Canada.
Insights
Transradial approach (TRA) failure in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) is low. A 9-variable risk score accurately predicts TRA-PCI failure, which is associated with worse outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Access
Background:
- The transradial approach (TRA) is increasingly used for primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI).
- Predictors of TRA failure in STEMI patients undergoing primary PCI require identification to optimize patient selection and procedural success.
Purpose of the Study:
- To identify predictors of TRA-PCI failure in STEMI patients.
- To develop and validate a novel risk score for predicting TRA-PCI failure in this population.
Main Methods:
- A retrospective analysis of 2020 consecutive STEMI patients undergoing primary PCI at a high-volume radial center.
- Multivariate analysis to identify independent predictors of TRA-PCI failure (defined as primary or crossover to transfemoral approach).
- Development and assessment of a 9-variable integer risk score for TRA-PCI failure prediction.
Main Results:
- TRA-PCI failure occurred in 5% of patients, with 2.2% requiring crossover to transfemoral approach (TFA).
- Independent predictors of TRA-PCI failure included low weight, physician experience, intra-aortic balloon pump use, cardiogenic shock, endotracheal intubation, elevated creatinine, advanced age, prior PCI, and hypertension.
- The developed risk score demonstrated high predictive accuracy (c-statistic of 0.868).
- TRA-PCI failure was associated with significantly higher 1-year mortality (adjusted OR 2.2).
Conclusions:
- TRA-PCI failure is infrequent in high-volume radial centers and can be accurately predicted by a 9-variable risk score.
- Given the inferior outcomes associated with TRA-PCI failure, strategies to maximize the utility of the radial approach in primary PCI warrant further investigation.
Objectives:
To determine predictors of failure of transradial approach (TRA) in patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and develop a novel score specific for this population.
Methods:
Consecutive patients with STEMI undergoing primary PCI in a tertiary care high-volume radial centre were included. TRA-PCI failure was categorised as primary (primary transfemoral approach (TFA)) or crossover (from TRA to TFA). Multivariate analysis was performed to determine independent predictors of TRA-PCI failure, and an integer risk score was developed. Clinical outcomes up to 1 year were assessed.
Results:
From January 2006 to January 2011, 2020 patients were studied. Primary TRA-PCI failure occurred in 111 (5%) patients and crossover to TFA in 44 (2.2%) patients. Independent predictors of TRA-PCI failure were: weight ≤65 kg (OR: 3.0; 95% CI 1.9 to 4.8, p<0.0001), physician with ≤5% TFA conversion (OR: 0.45; 95% CI 0.2 to 0.9, p=0.033), and physician with ≥10% conversion to TFA (OR: 2.2; 95% CI 1.2 to 3.7, p=0.005), intra-aortic balloon pump (OR: 2.0; 95% CI 0.9 to 4.3, p=0.066), cardiogenic shock (OR: 2.8; 95% CI 1.4 to 5.6, p=0.0035), endotracheal intubation (OR: 107; 95% CI 42 to 339, p<0.0001), creatinine >133 μmol/L (OR: 3.6; 95% CI 1.9 to 6.8, p<0.0001), age ≥75 (OR: 1.7; 95% CI 1.0 to 2.9, p=0.031), prior PCI (OR: 2.6; 95% CI 1.5 to 4.5, p=0.0009), hypertension (OR: 1.8; 95% CI 1.2 to 2.9, p=0.009). An integer risk score ranging from -1 to 12 was developed, and predicted TRA-PCI failure from 0% to 100% (c-statistic of 0.868; 95% CI 0.866 to 0.869). Mortality at 1 year remained significantly higher after TRA-PCI failure (adjusted OR 2.2; 95% CI 1.2 to 3.9, p=0.011).
Conclusions:
In a high-volume radial centre, the incidence of TRA-PCI failure is low and can be accurately predicted using a 9-variables risk score. Since outcomes after TRA-PCI failure remained inferior, further effort to maximise the use of radial approach for primary PCI should be investigated.
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