Choice of vascular access in primary PCI

Primary angioplasty (PPCI), introduced in the early '90s, has now become the preferred reperfusion strategy in ST-segment elevation myocardial infarction (STEMI). PPCI has traditionally been performed through transfemoral artery access (TFA) for about two decades. Such an access, however, has been associated to a not negligible rate of vascular complications and bleedings that, in turn, may significantly affect the overall prognosis. For this reason, transradial artery access (TRA), introduced by Campeau et al. in 1989 for diagnostic and by Kiemeneij et al. in 1993 for interventional procedures, and associated with significant reduction of vascular complications and bleedings in observational studies and registries, has been validated as alternative vascular access for PPCI procedures as well. However, because of its steep learning curve and for the smaller size of the radial artery compared with the femoral, concerns have been raised about its feasibility in urgent settings and in very complex cases. Despite these limitations, the advantages of TRA PPCI procedures have been confirmed by large nationwide registries and randomized trials, whose RIVAL, RIFLE-STEACS, STEMI RADIAL and MATRIX are the largest. All these studies showed that not only the vascular complications and bleedings, but the mortality and overall NACE (major cardiovascular events or major bleedings) were reduced as well. As a result, the TRA is now considered the "gold standard" access in the PPCI setting and has been endorsed by the european guidelines as the default access (class I, level of evidence A).