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Trends in Arterial Access Site Selection and Bleeding Outcomes Following Coronary Procedures, 2011-2018
Jacob A Doll1,2,3, Kristine Beaver1, Diana Naranjo4
1Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, WA (J.A.D., K.B., C.M., C.D.H.).
Insights
Radial access use in cardiac procedures increased significantly from 2011-2018, driven by both new and existing cardiologists. Despite declining bleeding rates, high-risk patients still more frequently receive femoral access, indicating a persistent risk/treatment paradox.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Healthcare Quality Improvement
Background:
- Radial access for cardiac catheterization is underutilized in high bleeding risk patients, a phenomenon known as the risk/treatment paradox.
- Prior studies focused on early adopters, necessitating an analysis of broader trends and operator behavior.
Purpose of the Study:
- To examine trends in radial access utilization for cardiac catheterization between 2011 and 2018.
- To determine if increased radial access adoption is driven by new or existing interventional cardiologists.
- To assess the association between rising radial access rates, postprocedural bleeding, and the persistence of the risk/treatment paradox.
Main Methods:
- A cross-sectional study analyzed data from 253,179 diagnostic angiograms and 93,614 percutaneous coronary interventions (PCI) in Veterans Affairs hospitals (2011-2018).
- Radial access rates and risk-adjusted bleeding rates were calculated, with temporal trends assessed using the Kendall Tau-b test.
- Separate bleeding risk models were developed for diagnostic angiography and PCI.
Main Results:
- Radial access use significantly increased for both diagnostic angiography (17.5% to 60.4%) and PCI (14.0% to 51.8%).
- Both existing and new operators increased radial access use, with new operators demonstrating higher baseline rates.
- Overall adjusted bleeding rates declined for diagnostic angiography but not for PCI, and patients with higher bleeding risk were more likely to undergo femoral access.
Conclusions:
- The increasing adoption of radial access for cardiac procedures is a widespread trend, influenced by both experienced and newly trained interventional cardiologists.
- While overall bleeding rates have decreased, the risk/treatment paradox persists, with high-risk patients still favoring femoral access.
- Further strategies are needed to ensure optimal access site selection for all patient risk profiles.
Background:
Prior studies of radial access for cardiac catheterization have focused on early adopters of the technique, and some have described a risk/treatment paradox of low radial access use among high bleeding risk patients. This study aimed to determine (1) trends in radial access use over time, (2) if increasing use of radial access is driven by new invasive and interventional cardiologists (operators) or existing operators changing their practice, and (3) if increasing radial rates are associated with lower bleeding rates and elimination of the risk/treatment paradox.
Methods:
In this cross-sectional study using data from the Clinical Assessment, Reporting, and Tracking Program, we calculated radial access rates and risk-adjusted postprocedural bleeding rates of patients undergoing diagnostic angiography or percutaneous coronary intervention (PCI) between 2011 and 2018 in Veterans Affairs hospitals. We used separate bleeding risk models for diagnostic angiography and PCI and assessed temporal trends with the Kendall Tau-b test.
Results:
Among 253 179 diagnostic angiograms and 93 614 PCIs, radial access rates increased over time for both diagnostic (17.5%-60.4%; P<0.01)) and PCI procedures (14.0%-51.8%; P<0.01). Existing operators and new operators increased their use at similar rates, but new operators entered practice with higher baseline rates. Nearly all operators used radial access at least once in 2018. Overall adjusted rates of bleeding declined, a trend that was significant for diagnostic angiography (2.4%-1.4%, P=0.02) but not PCI (3.4%-2.5%, P=0.20). Femoral access patients had a higher predicted risk for bleeding.
Conclusions:
A steady rise in radial access for diagnostic angiography and PCI was driven by increasing use among existing operators and high use by new operators. While this was associated with decreasing bleeding rates, a risk/treatment paradox for access site selection persists; patients at higher bleeding risk were still more likely to receive femoral access.
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