Systematic review/Meta-analysis Meta-analysis of randomized trials on access site selection for percutaneous coronary intervention in ST-segment elevation myocardial infarction (original) (raw)
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Indian Heart Journal, 2020
Background: This study was conducted with the aim of providing a quantitative appraisal of clinical outcomes of trans-radial access for primary percutaneous coronary interventions (PCI) in patients with ST-segment evaluation myocardial infarction (STEMI). Methods: In this study, we compared two propensity-matched cohorts of patients who underwent primary PCI via trans-radial (TRA) and trans-femoral access (TFA) in a 1:1 ratio. The profile of two cohorts was matched for gender, age, and body mass index, diabetes, hypertension, family history, and smoking. The outcomes of primary PCI were compared for the two cohorts which included all-cause in-hospital mortality, heart failure, re-infarction, cardiogenic shock, bleeding, transfusion, cerebrovascular accident, and dialysis. Results: This analysis was performed on a total of 2316 patients with 1158 patients each in the TRA and TFA group. We observed significantly lower rates of mortality, 0.8% (9) vs. 3.5% (41); p < 0.001 and bleeding, 0.5% (6) vs.1.6% (19); p ¼ 0.009 with shorter hospital stay, 1.61 ± 1.39 vs. 1.98 ± 1.5 days, in trans-radial vs. trans-femoral. However, both fluoroscopic time and contrast volume were significantly higher in the TRA as compared to TFA group 15.57 ± 8.16 vs. 12.79 ± 7.82 min; p < 0.001 and 143.22 ± 45.33 vs. 133.78 ± 45.97; p < 0.001 respectively. Conclusions: Compared with TFA access, TRA for primary PCI is safe for patients with STEMI, it was found to be associated with a significant reduction in in-hospital mortality and bleeding complications.
tranSition towardS tranSradiaL aPProacH iMProVeS oUtcoMeS of acUte MyocardiaL infarction Pci
introduction and aim: Transradial (TRA) instead of transfemoral (TFA) approach strategy has been presented in research literature as superior access strategy especially for acute ST elevation myocardial infarction (STEMI) primary percutaneous coronary intervention (PCI). There is a paucity of registry-based data of outcomes from default TRA strategy compared to TFA. Materials and methods: All-comers STEMI PCI institutional Registry identified 1808 consecutive patients in time-frame of 40 months from 2007 to 2010, without making any exclusions. Moreover, we applied Propensity Score Matching (PSM) to replace randomization, address the potential confounding and selection bias. PSM derived 565 congruent pairs of patients from the groups. results: After 30 days the primary composite endpoint of major adverse cardiovascular events (MACE) was in favor of TRA 6.5% vs. 12.4% in TFA group, simultaneously secondary endpoints of death in TRA with rate of 4.8% and with rate of 10.1% in TFA. More...
Catheterization and Cardiovascular Interventions, 2011
Objective: To evaluate if there are differences in procedural times, success rates, and safety between left and right radial approach (LRA and RRA, respectively) in primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). Background: Given conflicting reports of different procedural success with LRA vs. RRA, it is unclear if the side of radial access impacts in-room procedural times and success rates in primary PCI. At our institution the LRA has been commonly used in certain STEMI patients. Our clinical database was reviewed to see if routine use of the LRA could generate favorable technical success and reperfusion times as compared to the RRA. Methods: We retrospectively analyzed 135 consecutive STEMI patients treated with primary PCI performed via the left and right radial approach at our institution. Results: There were 50 cases in the LRA group and 85 in the RRA group. There was no difference in median procedural times including total procedure time (LRA 53.5 mins vs. RRA 52 mins, P 5 0.95), room-to-cannulation (LRA 12 min vs. RRA 13 min, P 5 0.40) or room-to-balloon times (LRA 30 min vs. RRA 31 min, P 5 0.74). There were no significant differences in procedural success rates (LRA 100% vs. RRA 97.6%, P 5 0.27), or procedure-related complications or death between the two groups. Conclusions: Left and right trans-radial approach for primary PCI have similar in room procedural times, success rates, and comparable safety. Trans-radial PCI through either arm is a feasible and safe approach in patients with STEMI.
American Heart Journal, 2015
Background The benefit of transradial access (TRA) in patients with cardiogenic shock (CS) is uncertain. We sought to determine the benefits of TRA in patients with CS undergoing coronary angiography/intervention. Methods MEDLINE, Embase, Cochrane Central, and electronic databases were searched for studies that assessed the following: (1) patients with CS who underwent percutaneous coronary intervention (PCI) and (2) the association between choice of arterial access, 30-day all-cause mortality, and 30-day major adverse cardiac and cerebral events (MACCEs) using random-effects model. Results From 3,652 retrieved citations, 8 studies involving 8,131 patients with CS undergoing PCI (via TRA: 2,321 patients, via TFA: 5,810 patients) were included. Transradial access was associated with significantly reduced risk for allcause mortality (unadjusted: risk ratio [RR] 0.60, 95% CI 0.52-0.71, P b .001, I 2 = 29%, 8 included studies; adjusted: RR 0.55, 95% CI 0.46-0.65, P b .001, I 2 = 0%, 6 included studies) and MACCE (unadjusted: RR 0.68, 95% CI 0.63-0.73, P b .001, I 2 = 0%, 6 included studies; adjusted: RR 0.63, 95% CI 0.52-0.75, P b .001, I 2 = 0%, 4 included studies) at 30 days when compared with TFA. Conclusions Transradial access is associated with reduced mortality and MACCE at 30 days in patients with CS undergoing PCI. Considering the possible influence of selection bias on the effect estimate in our analysis, randomized controlled trials are needed to better assess this association.
Risk-treatment paradox in the selection of transradial access for percutaneous coronary intervention
2013
Access site complications contribute to morbidity and mortality during percutaneous coronary intervention (PCI). Transradial arterial access significantly lowers the risk of access site complications compared to transfemoral arteriotomy. We sought to develop a prediction model for access site complications in patients undergoing PCI with femoral arteriotomy, and assess whether transradial access was selectively used in patients at high risk for complications. We analyzed 17 509 patients who underwent PCI without circulatory support from 2008 to 2011 at 5 institutions. Transradial arterial access was used in 17.8% of patients. In those who underwent transfemoral access, 177 (1.2%) patients had access site complications. Using preprocedural clinical and demographic data, a prediction model for femoral arteriotomy complications was generated. The variables retained in the model included: elevated age (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), female gender (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), elevated troponin (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), decreased renal function or dialysis (P=0.002), emergent PCI (P=0.01), prior PCI (P=0.005), diabetes (P=0.008), and peripheral artery disease (P=0.003). The model showed moderate discrimination (optimism-adjusted c-statistic=0.72) and was internally validated via bootstrap resampling. Patients with higher predicted risk of complications via transfemoral access were less likely to receive transradial access (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Similar results were seen in patients presenting with and without ST-segment myocardial infarction and when adjusting for individual physician operator. We generated and validated a model for transfemoral access site complications during PCI. Paradoxically, patients most likely to develop access site complications from transfemoral access, and therefore benefit from transradial access, were the least likely to receive transradial access.
European Heart Journal. Acute Cardiovascular Care
Objectives The purpose of this observational study was to evaluate the effects of radial artery access versus femoral artery access on the risk of 30-day mortality, inhospital bleeding and cardiogenic shock in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Methods We used data from the SWEDEHEART registry and included all patients who were treated with primary percutaneous coronary intervention in Sweden between 2005 and 2016. We compared patients who had percutaneous coronary intervention by radial access versus femoral access with regard to the primary endpoint of all-cause death within 30 days, using a multilevel propensity score adjusted logistic regression which included hospital as a random effect. Results During the study period, 44,804 patients underwent primary percutaneous coronary intervention of whom 24,299 (54.2%) had radial access and 20,505 (45.8%) femoral access. There were 2487 (5.5%) deaths within 30 days, of...
Journal of Cardiology & Current Research, 2018
Objectives: This study sought to assess whether transradial access improves clinical outcomes in patients with ST-segment elevation acute myocardial infarction (STEMI) compared with conventional transfemoral access. Background: In patients with STEMI the radial approach for PCI has been suggested to improve the prognosis due to a lower rate of vascular complications in comparision with femoral approach. Methods: This is a single-center, observational registry of all STEMI patients who underwent emergent coronary angiography between January 2016 to January 2017. The primary endpoint was the 30-day rate of net adverse clinical events (NACE), defined as a composite of death, MI, stroke, target vessel revascularization, BARC bleeding ≥3 and vascular complications. Secondary endpoints were 30-day individual components of NACEs and length of hospital stay. Results: The primary endpoint of 30-day NACE occurred in 6.4 % of the radial group (n: 218) and 12.1 % of the femoral group (n: 182; p=0.049). Compared with femoral, radial access was associated with significantly lower rates of BARC bleeding ≥3 (0.9 vs 3.8%, p=0.049) and shorter intensive coronary unit stay (2.04±2.3 vs 2.5±2.56, p=0.001). Mortality, stroke and myocardial infarction were similar in both groups. Multivariate regression analysis identified femoral approach as the only independent predictor of 30-day NACE (OR: 2.2; 95% CI: 1.0 to 4.7; p = 0.032). Conclusion: In patients with STEMI undergoing emergent PCI, radial access reduces net adverse clinical events, trough a reduction in BARC bleeding ≥3. The study supports the preferential use of radial access for STEMI PCI.
International Journal of Cardiology, 2016
Background: Trans-radial access for percutaneous coronary intervention (PCI) has been associated with lower vascular complication rates and improved outcomes. We assessed the current uptake of trans-radial PCI in Victoria, Australia, and evaluated if patients were selected according to baseline bleeding risk in contemporary clinical practise, and compared selected clinical outcomes. Methods: PCI data of all patients between 1st January 2013 and 31st December 2014 were analysed using The Victorian Cardiac Outcomes Registry (VCOR). Propensity-matched analysis was performed to compare the clinical outcomes. Results: 11,711 procedures were analysed. The femoral route was the predominant access site (66%). Patients undergoing trans-radial access PCI were younger (63.9 ± 11.6 vs. 67.2 ± 11.8; p b 0.001), had a higher BMI (28.9 ± 5.5 vs. 28.5 ± 5.2; p b 0.001), more likely to be male (80.0 vs. 74.9%;p b 0.001), less likely to have presented with cardiogenic shock (0.9 vs. 2.8%; p b 0.001) or have the following comorbidities: diabetes (19.8 vs. 23.1%; p b 0.001), peripheral vascular disease (2.9 vs. 4.3%; p = 0.005) or renal impairment (13.6 vs. 22.1%; p b 0.001). The radial group had less bleeding events (3.2 vs. 4.6%; p b 0.001) and shorter hospital length of stay (3.1 ± 4.7 vs. 3.3 ± 3.9; p = 0.006). There was no significant difference in mortality (1.0 vs. 1.4%; p = 0.095). Conclusions: Trans-femoral approach remains the dominant access site for PCI in Victoria. The choice of route does not appear to be selected by consideration of bleeding risk. The radial route is associated with improved clinical outcomes of reduced bleeding and length of stay consistent with previous findings, and this supports the efficacy and safety of trans-radial PCI in real-world clinical practise.