Author + information
- Received June 18, 2013
- Revision received August 2, 2013
- Accepted August 14, 2013
- Published online November 1, 2013.
- ∗Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- †Columbia University Medical Center/New York–Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
- ↵∗Reprint requests and correspondence:
Dr. Michael S. Lee, UCLA Medical Center, 100 Medical Plaza Suite 630, Los Angeles, California 90095.
Recent literature has argued the superiority of radial access compared with femoral access for percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS). Three particular trials—RIVAL (Radial Versus Femoral Access for Coronary Intervention), RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome), and STEMI-RADIAL (ST Elevation Myocardial Infarction Treated by Radial or Femoral Approach–Randomized Multicenter Study Comparing Radial Versus Femoral Approach in Primary PCI)—demonstrated lower rates of bleeding and vascular complications with the transradial approach. Bleeding is a major independent predictor of negative long-term outcomes including death, predisposes patients to transfusions, and attenuates the ability to administer cardioprotective post-procedural anticoagulation. These trials, however, employed suboptimal antithrombotic practices. Namely, the dose of heparin and percent of patients on glycoprotein IIb/IIIa inhibitors were unnecessarily high, and a paucity of patients were on bivalirudin, which decreases bleeding and improves outcomes compared with heparin and glycoprotein IIb/IIIa inhibitors. The use of larger gauge catheters in femoral access patients predisposed them to major bleeding and its subsequent complications. In addition, these trials were carried forth in high-volume transradial centers, further limiting the ability to generalize the findings to most PCI centers. These are important considerations especially for high-risk and ACS patients, in whom the negative implications of major bleeding are even greater. Without an optimized design, the applications of the trial findings are uncertain. Ultimately, a trial comparing femoral versus radial access in patients on bivalirudin, potent oral antiplatelet medication, and without adjunctive glycoprotein IIb/IIIa inhibitors is needed to assess outcomes based on access site alone.
Dr. Lee has received honoraria from Abiomed, St. Jude Medical, Medtronic, and Boston Scientific. Dr. Stone has served as a consultant to Boston Scientific. Dr. Wolfe has reported that he has no relationships relevant to the contents of this paper to disclose.
- Received June 18, 2013.
- Revision received August 2, 2013.
- Accepted August 14, 2013.
- American College of Cardiology Foundation