Randomised controlled trials have demonstrated that transradial (TR) percutaneous coronary intervention (PCI) reduces bleeding and improves survival compared with transfemoral access (TF). This benefit may be most marked in the context of primary PCI (pPCI) for ST-elevation myocardial infarction. Due to the learning curve associated with TR PCI, these benefits may not translate immediately into real-world practice.Our study sought to determine the effect on clinical outcomes, as our institution switched from TF to TR access.Methods
Consecutive patients presenting for PCI over a four year period (1.1.2008–31.12.2011) were included.The choice of access site and, interventional strategy were left to operator discretion. Haemorrhagic complications were identified and classified according to the Bleeding Academic Research Consortium (BARC) definitions.Results
8166 patients (mean age 64.8 ± 11.5 yrs, 76.2% male) were included. Over the study period, TR access became more prevalent (2008- 2.0%, 2011- 42.7%), and the haemorrhagic complication rate fell (2008- 1.64%, 2011- 0.95%, p = 0.05).TR PCI was associated with lower combined rates of BARC 2, 3 and 5 bleeding compared with TF access (0.30% vs. 1.45%, p < 0.001).This improvement was driven by lower rates of access-site related bleeding with TR PCI (TR 0.15% vs. TF 1.16%, p = 0.0009). There was no significant difference in non-access site related bleeding (TR 0.15% vs. TF 0.28%, p = 0.55).Results
As TR access became more prevalent (2009–11), a significant survival benefit was observed at 30 days (TR 99.4% vs. TF 98.5%, p = 0.01) and 1 year (TR 97.7% vs. TF 96.5%, p = 0.03).This benefit was most marked in pPCI (TR 98.0% vs. TF 95.7%, p = 0.06 at 30 days and TR 96.6% vs. TF 92.8%, p = 0.02 at 1 year), and occurred despite comparable levels of cardiogenic shock (TR 0.8% vs. TF 1.2%, p = 0.27) and chronic kidney disease (TR 0.7% vs. TF 1.1%, p = 0.21).Further analysis revealed that TR access was most beneficial in pPCI patients receiving glycoprotein IIb/IIIa inhibitors (1 year survival TR 99.2% vs. TF 93.5%, p = 0.01), with no survival benefit in those not receiving these drugs.Discussion
In real-world practice, despite the learning curve, TR access is associated with a reduced rate of access-site related bleeding and a significant survival benefit at 30 days and 1 year. This beneficial effect is most marked in pPCI and specifically when strong antithrombotic agents (e.g. glycoprotein IIb/IIIa inhibitors) are used. Our data supports the hypothesis that reduced bleeding may, in part, be responsible for the survival differences observed between TF and TR access.