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Updated: Dec 18, 2025
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Differential Use and Impact of Bleeding Avoidance Strategies on Percutaneous Coronary Intervention-Related Bleeding
Ty J Gluckman1, Lian Wang1, Kateri J Spinelli1
1Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, Portland, Oregon (T.J.G., L.W., K.J.S.).
Insights
Trans-radial intervention (TRI) consistently reduced bleeding risk in percutaneous coronary intervention (PCI) across all patient risk strata. Vascular closure device plus bivalirudin (VCD+BIV) also lowered bleeding risk for transfemoral PCI compared to no bleeding avoidance strategies.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Percutaneous coronary intervention (PCI) carries a risk of bleeding.
- Bleeding avoidance strategies (BAS) like bivalirudin (BIV), trans-radial intervention (TRI), and vascular closure devices (VCD) aim to mitigate this risk.
- The comparative effectiveness of BAS across different patient bleeding risk strata is not fully elucidated.
Purpose of the Study:
- To compare the impact of different BAS on PCI-related bleeding.
- To stratify the analysis by patient bleeding risk using a validated model.
- To identify which BAS are most effective in reducing bleeding across the spectrum of bleeding risk.
Main Methods:
- Retrospective cohort analysis of 74,953 PCIs across 18 facilities.
- Bleeding risk stratification using the National Cardiovascular Data Registry CathPCI bleeding model (6 categories).
- Regression models to assess the association between BAS (no BAS, BIV alone, TRI alone, VCD alone, TRI+BIV, VCD+BIV) and bleeding outcomes.
Main Results:
- The overall crude bleeding rate was 4.4%.
- Trans-radial intervention (TRI) alone showed significantly lower odds of bleeding compared to no BAS across all risk strata (OR range: 0.15-0.49).
- Vascular closure device plus bivalirudin (VCD+BIV) also demonstrated reduced bleeding odds compared to no BAS across all risk strata (OR range: 0.36-0.50).
- TRI showed lower bleeding odds than BIV alone, except in the highest risk percentile.
- Adding BIV to TRI did not alter bleeding odds.
Conclusions:
- Trans-radial intervention (TRI) is a consistently effective bleeding avoidance strategy across all patient bleeding risk levels.
- For transfemoral PCI, the combination of vascular closure device and bivalirudin (VCD+BIV) is effective in reducing bleeding.
- Factors limiting TRI use were infrequent in lower-risk procedures, suggesting broader applicability.
Background:
Procedural anticoagulation with bivalirudin (BIV), trans-radial intervention (TRI), and use of a vascular closure device (VCD) are thought to mitigate percutaneous coronary intervention (PCI)-related bleeding. We compared the impact of these bleeding avoidance strategies (BAS) for PCIs stratified by bleeding risk.
Methods:
We performed a retrospective cohort analysis of PCIs from 18 facilities within one health care system from 2009Q3 to 2017Q4. Bleeding risk was assessed per the National Cardiovascular Data Registry CathPCI bleeding model, with procedures stratified into 6 categories (first, second, third quartiles, 75th-90th, 90th-97.5th, and top 2.5th percentiles). Regression models were used to assess the impact of BAS on bleeding outcome.
Results:
Of 74 953 PCIs, 9.4% used no BAS, 12.0% used BIV alone, 20.8% used TRI alone, 26.8% used VCD alone, 5.4% used TRI+BIV, and 25.6% used VCD+BIV. The crude bleeding rate was 4.4% overall. Only 2 comparisons showed significant trends across all risk strata: VCD+BIV versus no BAS, odds ratio (95% CI) range: first quartile, 0.36 (0.18-0.72) to top 2.5th percentile, 0.50 (0.32-0.78); TRI versus no BAS, odds ratio (95% CI) range: first quartile, 0.15 (0.06-0.38) to top 2.5th percentile, 0.49 (0.28-0.86). TRI had lower odds of bleeding compared with BIV for all risk strata except the top 2.5th percentile. Addition of BIV to TRI did not change the odds of bleeding for any risk strata. Factors potentially limiting use of TRI (renal failure, shock, cardiac arrest, and mechanical circulatory support) were present in ≤10% of procedures below the 90th percentile.
Conclusions:
Among individual BAS, only TRI had consistently lower odds of bleeding across all risk strata. Factors potentially limiting TRI were found infrequently in procedures below the 90th percentile of bleeding risk. For transfemoral PCI, VCD+BIV had lower odds of bleeding compared with no BAS across all risk strata.
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