Comparison of radial versus femoral access in patients undergoing invasive management for acute coronary syndromes: evidence from a systematic review and meta-analysis G. Biondi-Zoccai,1 C. Moretti,1 F. Sciuto,1 P. Omedé,1 E. Cavallero,1 C. La Spina,1 V. Infantino,1 F. Colombo,1 E. Giraudi,1 E. Menditto,1 C. Iacovino,1 P. Agostoni,2 E. Romagnoli,3 M. Bollati,1 G. Trevi,1 I. Sheiban1 1University of Turin, Turin, Italy (gbiondizoccai@gmail.com); 2AZ Middelheim, Antwerp, Belgium; 3Policlinico Casilino, Rome, Italy

BACKGROUND An invasive management encompassing coronary angiography and, when indicated, percutaneous coronary intervention (PCI), is recommended in most high-risk patients with acute coronary sindromes (ACS). However, adverse events, especially local access site bleeding, are not uncommon. The radial approach has been proposed as an alternative to the femoral access to minimize bleedings in ACS, but data are so far unclear.

AIM OF OUR WORK We thus performed a comprehensive meta-analysis of randomized trials comparing radial vs femoral access in patients with ACS undergoing coronary angiography ± PCI.

METHODS We performed a meta-analysis of all studies published up to April 2008 comparing radial versus femoral access in patients with ACS, by means of systematic database search (clinicaltrials.gov, Google Scholar, PubMed), and data appraisal. The primary end-point was the occurrence of net adverse clinical events (NACE), defined as the composite of death, myocardial infarction (MI), repeat revascularization (ie major adverse cardiac events [MACE]) plus major bleeding. Odds ratios (OR) and weighted mean differences (WMD) were computed by means of fixed-effect methods.

Pts with femoral access INCLUDED STUDIES Study Year Pts with radial access Pts with femoral access STEMI (%) FARMI 2007 57 100% Mann et al 1998 68 77 14% RADIAL-AMI 2005 25 TEMPURA 2003 72

RESULTS A total of 4 randomized controlled trials were included, enrolling a total of 458 patients (227 randomized to radial access and 231 randomized to femoral access). Most (326) patients presented with acute ST-elevation myocardial infarction. At hospital discharge, the radial access was associated with significant reductions in the rate of net adverse clinical events in comparison to the femoral access (24/227 [10.5%] vs 36/231 [15.6%], p=0.05).

RESULTS Similarly beneficial yet statistically non-significant trends were also seen for death (7/227 [3.1%] vs 11/231 [4.8%]), major adverse cardiac events (21/227 [9.3%] vs 27/231 [11.7%]), and major bleedings (3/227 [1.3%] vs 9/231 [3.9%]; all p>0.05). Radial access was also associated with a significant reduction in length of hospital stay (weighted mean difference 1.0+-0.1 days, p<0.001).

RISK OF DEATH RISK OF MAJOR BLEEDING

RISK OF MACE RISK OF NACE

RISK OF ACCESS SITE COMPLICATIONS RISK OF PROCEDURAL FAILURE

TOTAL LENGTH OF HOSPITAL STAY IN DAYS Review: Radial vs femoral access in patients undergoing invasive management for acute coronary syndromes (1 August 2008) Comparison: 01 Comparison of radial versus femoral access for acute coronary syndromes Outcome: 07 Length of hospital stay Study Radial Femoral WMD (fixed) WMD (fixed) or sub-category N Mean (SD) N Mean (SD) 95% CI 95% CI Mann 1998 68 3.00(0.30) 77 4.50(0.50) -1.50 [-1.63, -1.37] TEMPURA 2003 77 5.70(4.90) 72 7.40(9.50) -1.70 [-4.15, 0.75] RADIAL-AMI 2005 25 4.00(1.00) 25 4.00(1.00) 0.00 [-0.55, 0.55] FARMI 2007 57 7.20(0.50) 57 7.50(0.40) -0.30 [-0.47, -0.13] Total (95% CI) 227 231 -1.00 [-1.10, -0.90] Test for heterogeneity: Chi² = 135.64, df = 3 (P < 0.00001), I² = 97.8% Test for overall effect: Z = 19.26 (P < 0.00001) -10 -5 5 10 Favors radial Favors femoral

CONCLUSIONS The radial access should be considered as the first choice vascular approach in most patients with unstable coronary artery disease managed invasively, given the evident overall clinical benefits. This holds even truer for those at higher risk of adverse events, such as the elderly, women and those undergoing rescue intervention for failed thrombolysis.

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