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It’s Time to Get With The Guidelines: The AHA Scientific Statement in Support of Transradial Artery Access for Coronary Angiography and Percutaneous Coronary Intervention in Acute Coronary Syndromes

Disclosure: None
Pub Date: Tuesday, September 4, 2018
Author: Zachary K. Wegermann, MD* and Sunil V. Rao, MD**
Affiliation:
                *Division of Cardiology, Duke University Medical Center
              **Division of Cardiology, Duke University Medical Center, and The Duke Clinical Research Institute

View the full Science News coverage for An Update on Radial Artery Access and Best Practices for Transradial Coronary Angiography and Intervention in Acute Coronary Syndrome

Citation

Mason PJ, Shah B, Tamis-Holland JE, Bittl JA, Cohen MG, Safirstein J, Drachman DE, Valle JA, Rhodes D, Gilchrist IC; on behalf of the American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Peripheral Vascular Disease; and Council on Genomic and Precision Medicine. An update on radial artery access and best practices for transradial coronary angiography and intervention in acute coronary syndrome: a scientific statement from the American Heart Association. Circ Cardiovasc Interv. 2018;11:e000035. DOI: 10.1161/HCV.0000000000000035

Article Text

Over the past two decades, transradial artery access (TRA) in coronary angiography and percutaneous coronary intervention (PCI) has transformed from a niche concept to an established technique with proven benefits. While early studies of TRA showed promise, they were limited by relatively small sample sizes and lacked bleeding avoidance strategies in the control femoral access arm. These limitations impeded the inclusion of TRA for reducing complications in past American professional society guidelines on PCI and the management of acute coronary syndromes (ACS)[1-4]. However, since the initial introduction of TRA, a comprehensive body of evidence has accrued demonstrating the superiority of TRA with respect to vascular complications, bleeding and mortality [5-9]. Despite these data, the uptake of TRA in the United States still lags behind many other nations, particularly in the setting of ACS. Possible limitations of to the adoption of TRA in ACS, particularly in ST-segment elevation myocardial infarction (STEMI), are the beliefs that transfemoral access (TFA) is associated with faster door-to-balloon times and higher rates of procedural success. To summarize the evidence on these issues and establish an expert consensus on the role of TRA, the American Heart Association working group led by Mason et al conducted a systematic review and meta-analysis, including trials published through June 2017. This document includes 19 randomized clinical trials (RCTs) involving 21,134 patients that compare TRA versus TFA in relationship to 3 major endpoints: bleeding, vascular complications, and mortality. The pooled data demonstrate an advantage of TRA across the measured endpoints, with a greater benefit with TRA in sicker patients and those with a higher risk of bleeding. The AHA Scientific Statement by Mason et al then goes on to articulate a clear set of recommendations and best practices to guide the transition to a radial first strategy in line with current evidence

Observational studies and RCTs have shown that TRA reduces bleeding and vascular complications compared with TFA [5-18]. While the main driver for the reduction in bleeding in some trials was a reduced rate of minor or access site bleeding, other data show that both minor and major bleeding are associated with increased mortality [5, 8, 19, 20]. In the meta-analysis by Mason et al, major bleeding rates were lower in TRA compared with TFA, both in stable ischemic heart disease and ACS. The bleeding rate for TRA was 3.4% and 5.5% for TFA in this meta-analysis, with a NNT of 47 for TRA to prevent one major bleeding event. More striking are the data for reductions in vascular access complications with TRA compared with TFA. The AHA statement shows that the rate of major vascular access complications with TRA was 2.9% versus 7.7% with TFA. This equates to NNT of 21 patients with TRA to prevent one vascular complication.

Reductions in bleeding and vascular complications with TRA are accompanied by a significant reduction in mortality in ACS patients when all the randomized trial data are pooled. Smaller individual trials were not specifically powered for mortality. For example, the STEMI-RADIAL trial enrolled 707 STEMI patients undergoing primary PCI and did not show a difference in mortality between TRA and TFA. However, the RIVAL, MATRIX, and RIFLE-STEACS trials demonstrated a mortality benefit with TRA compared with TFA in ACS, and included over 16,000 patients. The meta-analysis by Mason et al shows that mortality was not different between TRA and TFA when patients with both stable ischemic heart disease and ACS were combined. However, when focused on the pooled ACS patient population alone, mortality was significantly lower in patients assigned to TRA.

A common argument against the routine use of TRA for primary PCI is that radial access and transradial PCI take longer than transfemoral PCI, potentially prolonging door-to-balloon time. While this may be true for novice TRA operators, the available data show there is no significant difference between door-to-balloon times, nor a difference in procedural success between TRA and TFA in the setting of ACS [5-7, 11, 21, 22], with the caveat that the operators included in these studies were likely very experienced with TRA. An observational study from the ACC-NCDR registry study showed that TRA was associated with a four minute mean increase in procedure time compared with TFA in STEMI cases, but clinical outcomes still favored radial access [23].  Additionally, a decision analytic modeling study using pooled mortality data from the RIVAL and RIFLE-STEACS trials showed that a substantial delay in reperfusion times, between 20-80 minutes beyond the 90 minute benchmark, was required to offset the mortality benefit of TRA access in PCI [24].

The economic impact of arterial access sites in coronary angiography and PCI is a topic of ongoing research. Current data suggests a cost savings associated with TRA compared to TFA, driven by reductions in bleeding and vascular complications, and the resultant decrease in length of ICU and hospital stays. The cost reductions afforded by TRA become more apparent in higher bleeding risk patients, such as patients with ACS and particularly patients with STEMI.

Given the data favoring TRA, Mason et al sketch out a set of best practice recommendations in TRA for treatment of ACS. One important point outlined in the document is that operators and cath lab teams should become proficient in TRA in non-emergent cases prior to deploying a radial first strategy in ACS. Requisite case volumes to achieve and maintain proficiency have been suggested to overcome the learning curve associated with TRA PCI. Approximately 30-50 cases are needed to overcome this learning curve and see reductions in contrast use and radiation exposure [25]. Importantly, mortality, bleeding and vascular complications remain low across TRA volumes, suggesting patient safety is not compromised during this period [25]. Additionally, the relationship between case volume and procedural success does not appear to have a threshold [25, 26]. Other important concepts addressed in the document include the role of collateral testing of hand circulation to triage for radial artery access, use of ultrasound guidance, and maintaining proficiency in femoral artery access. The RADAR study has demonstrated that conventional wisdom surrounding collateral circulation is not accurate in predicting TRA safety [27]. Additionally, use of ultrasound in access increases procedural success. Transitioning to a radial first strategy should not limit centers or operators understanding and maintenance of femoral artery access techniques and best practices as TFA is employed in many other procedures such as percutaneous ventricular assist devices, structural heart cases, and peripheral vascular interventions.

The current AHA Scientific Statement provides an important summary of the data on TRA, particularly in the setting of ACS. The available data support the role of TRA as the preferred route of access in ACS patients due to its superior safety profile. Not only does TRA PCI reduce major bleeding events and vascular access site complications, it also has a mortality benefit in ACS. In addition to its favorable patient outcomes, data suggest it is preferred by patients and leads to reductions in costs to the healthcare system. As such, the data support the conclusion by Mason et al that a shift to a radial first strategy in ACS is recommended. The AHA Scientific Statement goes on to establish recommendations for the application of TRA, giving welcome guidance to physicians and health systems seeking to implement best practices in TRA.

References

  1. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013; 127:e362-425.
  2. Levine GN, O’Gara PT, Bates ER, et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: An update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Circulation. 2016; 133:1135-1147.
  3. Levine GN, Bates ER, Blanksenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. JACC. 2011; 58 (24):e44-122.
  4. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the management of patients with Non-ST-Elevation Acute Coronary Syndromes. Circulation. 2014; 130: 2354-2394.
  5. Jolly SS, Yusuf S, Cairns J, Niemela K, Xavier D, Widimsky P, Budaj A, Niemela M, Valentin V, Lewis BS, Avezum A, Steg PG, Rao SV, Gao P, Afzal R, Joyner CD, Chrolavicius S, Mehta SR. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377:1409-1420
  6. Valgimigli M, Gagnor A, Calabro P, Frigoli E, Leonardi S, Zaro T, Rubartelli P, Briguori C, Ando G, Repetto A, Limbruno U, Cortese B, Sganzerla P, Lupi A, Galli M, Colangelo S, Ierna S, Ausiello A, Presbitero P, Sardella G, Varbella F, Esposito G, Santarelli A, Tresoldi S, Nazzaro M, Zingarelli A, de Cesare N, Rigattieri S, Tosi P, Palmieri C, Brugaletta S, Rao SV, Heg D, Rothenbuhler M, Vranckx P, Juni P, Investigators M. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015;385:2465-2476.
  7. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, Politi L, Rigattieri S, Pendenza G, Summaria F, Patrizi R, Borghi A, Di Russo C, Moretti C, Agostoni P, Loschiavo P, Lioy E, Sheiban I, Sangiorgi G. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012;60:2481-2489
  8. Bernat I, Horak D, Stasek J, Mates M, Pesek J, Ostadal P, Hrabos V, Dusek J, Koza J, Sembera Z, Brtko M, Aschermann O, Smid M, Polansky P, Al Mawiri A, Vojacek J, Bis J, Costerousse O, Bertrand OF, Rokyta R. ST-segment elevation myocardial infarction treated by radial or femoral approach in a multicenter randomized clinical trial: the STEMI-RADIAL trial. J Am Coll Cardiol. 2014;63:964-972
  9. Mehta SR, Jolly SS, Cairns J, Niemela K, Rao SV, Cheema AN, Steg PG, Cantor WJ, Dzavik V, Budaj A, Rokoss M, Valentin V, Gao P, Yusuf S, Investigators R. Effects of radial versus femoral artery access in patients with acute coronary syndromes with or without ST-segment elevation. J Am Coll Cardiol. 2012;60:2490-2499.
  10. Feldman DN, Swaminathan RV, Kaltenbach LA, Baklanov DV, Kim LK, Wong SC, Minutello RM, Messenger JC, Moussa I, Garratt KN, Piana RN, Hillegass WB, Cohen MG, Gilchrist IC, Rao SV. Adoption of radial access and comparison of outcomes to femoral access in percutaneous coronary intervention: an updated report from the national cardiovascular data registry (2007-2012). Circulation. 2013;127:2295-2306.
  11. Ratib K, Mamas MA, Anderson SG, Bhatia G, Routledge H, De Belder M, Ludman PF, Fraser D, Nolan J, British Cardiovascular Intervention S, the National Institute for Cardiovascular Outcomes R. Access site practice and procedural outcomes in relation to clinical presentation in 439,947 patients undergoing percutaneous coronary intervention in the United kingdom. JACC Cardiovasc Interv. 2015;8:20-29.
  12. Azamendi D, Quoc Ly H, Languay JF. Effect on bleeding, time to revascularization, and one-year clinical outcomes the radial approach during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. Am J Cardiol. 2010; 106:148-154.
  13. Fefer P, Matetzky S, Gannot S et al. Predictors and outcomes associated with radial versus femoral access for intervention in patients with acute coronary syndrome in a real-world setting: results from the Acute Coronary Syndrome Israeli Survey (ACSIS) 2010. J Invasive Cardiol. 2014;26:398-402.
  14. Genereux P, Mehran R, Palmerini T et al. Radial access in patients with ST-segment elevation myocardial infarction undergoing primary angioplasty in acute myocardial infarction: the HORIZONS-AMI trial. EuroIntervention. 2011;7:905-916.
  15. Iqbal MB, Arujuna A, Ilsley C et al. Radial versus femoral access is associated with reduced complications and mortality in patients with non-ST-segment-elevation myocardial infarction: an observational cohort study of 10,095 patients. Circ Cardiovasc Interv. 2014;7:456-464.
  16. Kadakia MB, Rao SV, McCoy L et al. Transradial Versus Transfemoral Access in Patients Undergoing Rescue Percutaneous Coronary Intervention After Fibrinolytic Therapy. JACC Cardiovasc Interv. 2015;8:1868-1876.
  17. Kwok CS, Khan MA, Rao SV et al. Access and non-access site bleeding after percutaneous coronary interventions and risk of subsequent mortality and major adverse cardiovascular events: systematic review and meta-analysis. Circ Cardiovasc Interv. 2015;8:e001645. DOI: 10.1161/CIRCINTERVENTIONS.114.001645.
  18. De Carlo M, Borelli G, Gistri R et al. Effectiveness of the transradial approach to reduce bleedings in patients undergoing urgent coronary angioplasty with GPIIb/IIIa inhibitors for acute coronary syndromes. Catheter Cardiovasc Interv. 2009;74:408-415.
  19. Rao SV, McCoy LA, Spertus JA, Krone RJ, Singh M, Fitzgerald S, Peterson ED. An updated bleeding model to predict the risk of post-procedure bleeding among patients undergoing percutaneous coronary intervention: a report using an expanded bleeding definition from the National Cardiovascular Data Registry CathPCI Registry. JACC Cardiovasc Interv. 2013;6:897-904.
  20. Mehran R, Pocock S, Nikolsky E et al. Impact of bleeding on mortality after percutaneous coronary intervention results from a patient-level pooled analysis of the REPLACE-2 (randomized evaluation of PCI linking angiomax to reduced clinical events), ACUITY (acute catheterization and urgent intervention triage strategy), and HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trials. JACC Cardiovasc Interv. 2011;4:654-464.
  21. Rao SV, Cohen MG, Kandzari DE, Bertrand OF, Gilchrist IC. The transradial approach to percutaneous coronary intervention: historical perspective, current concepts, and future directions. J Am Coll Cardiol. 2010;55:2187-2195.
  22. Michael TT, Alomar M, Papayannis A et al. A randomized comparison of the transradial and transfemoral approaches for coronary artery bypass graft angiography and intervention: the RADIAL-CABG Trial (RADIAL Versus Femoral Access for Coronary Artery Bypass Graft Angiography and Intervention). JACC Cardiovasc Interv. 2013;6:1138-1144.
  23. Baklanov DV, Kaltenbach LA, Marso SP, et al. The prevalence and outcomes of transradial percutaneous coronary intervention for ST-segment elevation myocardial infarction. Analysis from the National Cardiovascular Data Registry (2007 to 2001). J Am Coll Cardiol. 2013;61(4):420-426.
  24. Wimmer NJ, Cohen DJ, Wasfy JH, et al. Delay in reperfusion with transradial percutaneous coronary intervention for ST-elecation myocardial infarction: Might some delays be acceptable? Am Heart J. 2014;168(1):103-109.
  25. Hess CN, Peterson ED, Neely ML, Dai D, Hillegass WB, Krucoff MW, Kutcher MA, Messenger JC, Pancholy S, Piana RN and Rao SV. The learning curve for transradial percutaneous coronary intervention among operators in the United States: a study from the National Cardiovascular Data Registry. Circulation. 2014;129:2277-2286.
  26. Pristipino C, Roncella A, Trani C, et al. Prospective Registry of Vascular Access Intervention in Lazo region (PREVAIL) study group. Identifying factors that predict the choice and success rate of radial artery catheterization in contemporary real world cardiology practice: a sub-analysis of the PREVAIL study data. EuroIntervention. 2010;109:813-819.
  27. Valgimigli M et al Transradial coronary catheterization and intervention across the whole spectrum of Allen test results (RADAR Trial) J Am Coll Cardiol. 2014;63:1833-1841.

-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --