Systematic review and cost-benefit analysis of radial artery access for coronary angiography and intervention

Abstract

Background: Radial artery access for coronary angiography and interventions has been promoted for reducing hemostasis time and vascular complications compared with femoral access, yet it can take longer to perform and is not always successful, leading to concerns about its cost. We report a cost-benefit analysis of radial catheterization based on results from a systematic review of published randomized controlled trials.

Methods and results: The systematic review added 5 additional randomized controlled trials to a prior review, for a total of 14 studies. Meta-analyses, following Cochrane procedures, suggested that radial catheterization significantly increased catheterization failure (OR, 4.92; 95% CI, 2.69-8.98), but reduced major complications (OR, 0.32; 95% CI, 0.24-0.42), major bleeding (OR, 0.39; 95% CI, 0.27-0.57), and hematoma (OR, 0.36; 95% CI, 0.27-0.48) compared with femoral catheterization. It added approximately 1.4 minutes to procedure time (95% CI, -0.22 to 2.97) and reduced hemostasis time by approximately 13 minutes (95% CI, -2.30 to -23.90). There were no differences in procedure success rates or major adverse cardiovascular events. A stochastic simulation model of per-case costs took into account procedure and hemostasis time, costs of repeating the catheterization at the alternate site if the first catheterization failed, and the inpatient hospital costs associated with complications from the procedure. Using base-case estimates based on our meta-analysis results, we found the radial approach cost $275 (95% CI, -$374 to -$183) less per patient from the hospital perspective. Radial catheterization was favored over femoral catheterization under all conditions tested.

Conclusions: Radial catheterization was favored over femoral catheterization in our cost-benefit analysis.

Figure 1. PRISMA flow diagram

PRISMA diagram of search results and article flow

Figure 2. Sensitivity analysis

Tornado diagram showing the effect of changes in each cost component variable on the net cost savings of radial catheterization as compared to femoral catheterization. Baseline values from our meta-analyses are indicated by the vertical dotted line. None of the changes to the component variables tip the balance of costs in favor of femoral catheterization.

Figure 3. Effect of radial access procedure time on cost savings

Figure 3. Relationship of procedure time difference between radial and femoral catheterization and cost savings with radial catheterization. The dotted line represents the actual difference in procedure time as determined by the meta-analysis. If radial and femoral procedures take the same time, the model concludes that radial catheterization will be $297 less costly. The cost advantage of radial catheterization disappears only if it takes approximately 20 minutes longer than femoral catheterization.

Figure 4. Effect of reducing femoral access complication rate on cost-savings of the radial access strategy

Figure 4. Using baseline risks of femoral and radial catheterization from the meta-analyses, radial catheterization saves $275 per patient. Risks of femoral catheterization must be reduced by approximately 60% with no corresponding change to radial risk in order for the net costs to be equal.