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Published on: June 12, 2021
Transradial access in acute myocardial infarction complicated by cardiogenic shock: Stratified analysis by shock
Behnam N Tehrani1, Abdulla A Damluji1,2, Matthew W Sherwood1
1Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia.
Insights
Transradial access (TRA) is feasible for acute myocardial infarction with cardiogenic shock (AMI-CS), reducing bleeding complications. Ultrasound-guided transfemoral access also lowers bleeding and vascular issues in these critical patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Access
Background:
- Transradial access (TRA) improves outcomes in acute myocardial infarction (AMI).
- Limited data exist on TRA in AMI complicated by cardiogenic shock (CS).
- This study assesses TRA safety, feasibility, and outcomes in AMI-CS patients.
Purpose of the Study:
- To evaluate the safety and feasibility of transradial access (TRA) in patients with acute myocardial infarction and cardiogenic shock (AMI-CS).
- To compare clinical outcomes, including bleeding and procedural success, between TRA and transfemoral access (TFA) in AMI-CS.
Main Methods:
- 153 patients with AMI-CS were stratified by CardShock score.
- Primary endpoint: successful percutaneous coronary intervention (PCI) with survival to 30 days.
- Comparison of TRA versus TFA, with analysis of bleeding events and vascular complications.
Main Results:
- TRA was preferred in lower disease severity groups.
- Major adverse events occurred in 32% of patients, predominantly with TFA.
- TRA was associated with reduced access-site bleeding compared to TFA, especially when ultrasound guidance was used for TFA.
Conclusions:
- Transradial access (TRA) is feasible across the spectrum of AMI-CS, with reduced access-site bleeding.
- Ultrasound-guided transfemoral access (TFA) also reduces bleeding and vascular complications.
- Integrating vascular access protocols into cardiogenic shock algorithms is recommended for dedicated shock centers.
Background:
Transradial access (TRA) is associated with improved survival and reduced vascular complications in acute myocardial infarction (AMI). Limited data exist regarding TRA utilization and outcomes for AMI complicated by cardiogenic shock (CS). We sought to assess the safety, feasibility, and clinical outcomes of TRA in AMI-CS.
Methods:
One-hundred and fifty-three patients with AMI-CS were stratified into tertiles of disease severity using the CardShock score. The primary endpoint was successful percutaneous coronary intervention (PCI), defined as Thrombolysis in Myocardial Infarction III flow with survival to 30 days.
Results:
Mean age was 66 years, 72% were men, and 47% had diabetes. TRA was the preferred access site in patients with low and intermediate disease severity. Overall, 50 (32%) patients experienced major adverse cardiac and cerebrovascular events; most events (78%) occurred in patients undergoing transfemoral access (TFA) in the intermediate-high tertiles of CS severity. Of the 41 (27%) total bleeding events, 32% occurred at the coronary angiography access site, of which 92% were in the TFA group. The use of ultrasound (US) guidance for TFA resulted in reduced coronary access-site bleeding (8.5 vs. 33.0%, p = .01). In a hierarchical logistic regression model, utilizing TRA did not result in lower odds of successful PCI (Odds ratio [OR]: 1.36; 95% confidence interval [CI]: 0.54-3.40).
Conclusion:
This study suggests that TRA is feasible across the entire spectrum of AMI-CS and is associated with reduced coronary access-site bleeding. In addition, US-guided TFA is associated with reductions in access-site bleeding and vascular complications. Concerted efforts should be made to incorporate vascular access protocols into existing CS algorithms in dedicated shock care centers.
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