1. 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

2. 12 randomized trials. 3224 patients
Entry Site Complications. Fem vs Rad Metanalysis. Agostoni, Hammond et al. JACC 2004;44:349-60
12 randomized trials patients
Radial 0.3% vs Femoral 2.8%
OR 0.20; p<0.0001

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

4. 2.820,874 PCIs ,643 radial
2.642,231 femoral

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

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

8. Bleeding and Mortality

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

10. 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

11. 13% of study sites did not perform any r-PCI
22 sites performed r-PCI in >50% of all PCIs

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

14. 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

16. RIFLE STEACS – results 30-day NACE predictors OR CI 95% p value
Female gender
1.5
( )
0.037
CKD
2.1
( )
0.001
Radial access
0.6
( )
0.012
Killip class
1.8
( )
LAD culprit
1.7
( )
0.006
TIMI 0 basal
1.4
( )
0.073
LVEF <50%
1.6
( )
0.025
TIMI 0-1 final
2.4
( )
0.024
p= 0.002

17. 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

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

19. 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

20. 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

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

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

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

24. 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

25. 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%

26. 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

27. The end