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Radial access first for PCI in acute coronary syndrome : Are we propping up a straw man?
Jeffrey A Marbach1, Saad Alhassani1, George Wells2
1CAPITAL Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, 40 Ruskin Street, K1Y 4W7, Ottawa, ON, Canada.
Insights
Percutaneous coronary intervention (PCI) via radial artery access reduces bleeding complications compared to femoral artery access. Recent trials question this benefit in contemporary settings, prompting a review of existing evidence for PCI access site selection in acute coronary syndrome.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Access
Background:
- Percutaneous coronary intervention (PCI) is standard for acute coronary syndrome (ACS).
- Access site bleeding is a major PCI complication, increasing costs and mortality.
- Radial artery (RA) access is favored over femoral artery (FA) access due to lower bleeding rates.
Purpose of the Study:
- To review evidence supporting current guidelines recommending radial artery access for PCI in ACS patients.
- To evaluate recent trials, like SAFARI-STEMI, that challenge the universal benefit of radial access.
- To provide context for understanding PCI access site selection in ACS.
Main Methods:
- Review of background studies and major randomized trials comparing RA vs. FA access in ACS patients.
- Analysis of evidence influencing current European and Canadian cardiovascular guidelines.
- Consideration of contemporary bleeding-reduction strategies in recent trials.
Main Results:
- Multiple trials show reduced bleeding with RA compared to FA access for PCI.
- RA access may also reduce mortality in ACS patients.
- Recent studies using modern bleeding-reduction techniques question the definitive superiority of RA access.
Conclusions:
- Current guidelines recommend radial artery access as the default strategy for PCI in ACS.
- The SAFARI-STEMI trial suggests radial artery access benefits may be less pronounced with advanced bleeding-reduction protocols.
- Further evaluation of PCI access site strategies in ACS is warranted.
Abstract:
Coronary angiography and percutaneous coronary intervention (PCI) represent the recommended revascularization strategy for patients presenting with acute coronary syndrome (ACS). However, periprocedural bleeding events, of which up to 50% are related to the access site, remain an important complication of PCI and are associated with higher costs, prolonged hospital stays, and increased mortality. Several randomized trials have demonstrated that PCI performed via radial artery (RA) access is associated with a reduction in bleeding events, and perhaps a reduction in mortality compared with femoral artery (FA) access. As a result, current practice guidelines from the European Society of Cardiology and the Canadian Cardiovascular Society recommend that RA be the default strategy for PCI in patients presenting with ACS. The recently published Safety and Efficacy of Femoral Access vs. Radial Access in ST-Segment Elevation Myocardial Infarction (SAFARI-STEMI) trial challenges the benefits of a default RA approach in a contemporary setting where additional bleeding-reduction strategies (i.e., avoidance of glycoprotein IIb/IIIa inhibitors, routine use of bivalirudin for procedural anticoagulation, and vascular closure devices) were employed. In order to better understand the evidence that has shaped the current recommendations, we present a review of the background studies and major randomized trials comparing RA with FA in patients presenting with ACS.
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