Influence of arterial access site selection on outcomes in primary percutaneous coronary intervention: are the results of randomized trials achievable in clinical practice?

Abstract

Objectives: This study sought to investigate the influence of access site utilization on mortality, major adverse cardiac and cardiovascular events (MACCE), bleeding, and vascular complications in a large number of patients treated by primary percutaneous coronary intervention (PPCI) in the United Kingdom over a 5-year period, through analysis of the British Cardiovascular Intervention Society database.

Background: Despite advances in antithrombotic and antiplatelet therapy, bleeding complications remain an important cause of morbidity and mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing PPCI. A significant proportion of such bleeding complications are related to the access site, and adoption of radial access may reduce these complications. These benefits have not previously been studied in a large unselected national population of PPCI patients.

Methods: Mortality (30-day), MACCE (a composite of 30-day mortality and in-hospital myocardial re-infarction, target vessel revascularization, and cerebrovascular events), and bleeding and access site complications were studied based on transfemoral access (TFA) and transradial access (TRA) site utilization in PPCI STEMI patients. The influence of access site selection was studied in 46,128 PPCI patients; TFA was used in 28,091 patients and TRA in 18,037. Data were adjusted for potential confounders using Cox regression that accounted for the propensity to undergo radial or femoral approach.

Results: TRA was independently associated with a lower 30-day mortality (hazard ratio [HR]: 0.71, 95% confidence interval [CI]: 0.52 to 0.97; p < 0.05), in-hospital MACCE (HR: 0.73, 95% CI: 0.57 to 0.93; p < 0.05), major bleeding (HR: 0.37, 95% CI: 0.18 to 0.74; p < 0.01), and access site complications (HR: 0.38, 95% CI: 0.19 to 0.75; p < 0.01).

Conclusions: This analysis of a large number of PPCI procedures demonstrates that utilization of TRA is independently associated with major reductions in mortality, MACCE, major bleeding, and vascular complication rates.

Keywords: AMI; BCIS; British Cardiovascular Intervention Society; CABG; CI; GP; HR; IABP; MACCE; OR; PCI; PPCI; ST-segment elevation myocardial infarction; STEMI; TFA; TRA; access site; acute myocardial infarction; confidence interval; coronary artery bypass grafting; femoral; glycoprotein; hazard ratio; intra-aortic balloon pump; major adverse cardiac and cerebrovascular event(s); odds ratio; outcomes; percutaneous coronary intervention; primary percutaneous coronary intervention; radial; transfemoral access; transradial access.