Pros and Cons of Radial Access A Pichard, I Ben-Dor, L Satler, Ron Waksman, W Suddath, N Bernardo, R Gallino, R Lager. Medstar Washington Hospital Center Washington, DC

12 randomized trials. 3224 patients Entry Site Complications. Fem vs Rad Metanalysis. Agostoni, Hammond et al. JACC 2004;44:349-60 12 randomized trials. 3224 patients Radial 0.3% vs Femoral 2.8% OR 0.20; p<0.0001

Procedural Differences. Metanalysis Fem vs Rad. Agostini, Hammond et al. JACC 2004;44:349-54 3224 pts randomized

2.820,874 PCIs. 178,643 radial 2.642,231 femoral

Radial mega-analysis N=76 studies (15 rand; 61 obs); 761,919 patients Bertrand OF, et. al. AHJ 2012

PCI in USA 2.820,874 PCIs 178,643 radial 2.642,231 femoral

Bleeding and Mortality

Bleeding and Vascular Complications NCDR. Rao et al. JACC Interv

Bleeding in Stable angina, NSTEMI, & STEMI Cath-PCI Rates. Rao SV et al. JACC 2010 Overall rate = 2.1% NSTEMI Overall rate = 4.8% STEMI Overall rate = 12.7% Access site bleeds are 29.8% of all bleeds

13% of study sites did not perform any r-PCI 22 sites performed r-PCI in >50% of all PCIs

Rad vs Fem in ACS RIVAL Study. Mehta et al. JACC 2012;60:2490-9 7021 patients randomized. 1958 STEMI, 5063 NSTEACS

RIFLE STEACS – R vs F in STEMI 1001 patients randomized p = 0.003 21.0 17.3 p = 0.029 p = 0.026 13.6 12.2 11.4 10.0 9.3 7.8 7.2 Net Adverse Clinical Event (NACE) = MACCE + bleeding Major Adverse Cardiac and Cerebrovascular event (MACCE) = composite of cardiac death, myocardial infarction, target lesion revascularization, stroke Bleeding Academic Research Consortium (BARC) = bleeding definition adopted 14

RIFLE STEACS – results 30-day NACE predictors OR CI 95% p value Female gender 1.5 (1.1-2.3) 0.037 CKD 2.1 (1.4-3.1) 0.001 Radial access 0.6 (0.4-0.9) 0.012 Killip class 1.8 (1.5-2.2) LAD culprit 1.7 (1.2-2.6) 0.006 TIMI 0 basal 1.4 (1.0-2.1) 0.073 LVEF <50% 1.6 (1.1-2.5) 0.025 TIMI 0-1 final 2.4 (1.1-5.1) 0.024 p= 0.002

RIFLE STEACS - conclusions Radial access in STEACS is associated with significant clinical benefits (lower morbidity and mortality). Radial approach should become the recommended access site for STEACS (international guideline). 17

Radial vs. Femoral in STEMI N=3347 pts from randomized, case-control, and cohort studies incl. RIVAL Pooled odds ratio for Mortality 0.53 (0.33-0.84) Pooled increase in procedure time 1.76 min (0.59, 2.92) 1.0 Favors femoral Favors radial Joyal D, et. al. AJC 2012

RADIAL in PCI Guidelines. ACCF/AHA/SCAI 5.1. Vascular Access: Recommendation The use of radial artery access can be useful to decrease access site complications.255,260,356–362 Class IIa (Level of Evidence: A) 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

ESC Guideline for Primary PCI ESC Guideline for Primary PCI. European Heart Journal (2012) 33, 2569–2619 If performed by an experienced operator, radial should be preferred over femoral access

Radial vs Femoral in Cardiogenic Shock Pancholy SB et al. Favors TRA Favors TFA

Radial Artery Patency and Anticoagulation n=49 n=119 n=210 *Assessed by Doppler examination Spaulding, et al. Cathet Cardiovasc Diag 1996;39:365-370

Radiation exposure in Rt vs Lt Radial. Rigatieri et all. TCT 2014 1464 patients

Radial Access Improvements New guiding catheters New Glide sheaths New Slender Sheaths Long glide sheaths (25 cm) New thin wall catheters (smaller French). Good radial compression devices

TRI Ratio in Each Region (2011) Europe 1,300,000 USA 1,100,000 China 300,000 18% 25% Japan 225,000 80% Mid-East 95,000 Asia 110,000 70% 20% India 160,000 20% Latin America 120,000 33% 20% Australia/New Zealand 46,000 20%

Conclusions Radial access is: Simple and safe. Best for patient satisfaction. Less complications. Specially indicated in STEMI. Almost eliminates access bleeding. Improves Outcomes Best for Cath Lab turn over. Femoral Access: still a viable option

The end