The impact of transradial versus transfemoral approach for percutaneous coronary intervention on the outcome of patients presenting with acute coronary syndrome

Abstract

SUMMARY A cute coronary syndromes (ACS) with and without ST-segment elevation are most commonly caused by rupture of an atherosclerotic plaque, leading to thrombin generation, platelet activation, and thrombus formation. These patients remain at high risk for ischemic events, both early during the initial hospitalization and long term. In patients with ACS, major bleeding is as common as recurrent myocardial infarction and occurs in about 5% of patients. A substantial proportion of the bleeding occurs at the vascular access site. Bleeding is associated with an increased risk of adverse outcomes, including MI, stroke, and death. The transfemoral approach (TFA) has been until presently the main-stay for arterial access PCI in the setting of acute STEMI, while the transradial approach (TRA) is gaining ground in elective as well as primary procedures. The main complications of femoral artery access are hematoma, arteriovenous fistula, arterial pseudoaneurysm, and retroperitoneal hemorrhage. These complications are responsible for most of the bleeding that occurs in invasive procedures, especially in ACS & they are influenced by anatomic features, obesity, and puncture technique. The current study aimed at assessing the impact of transradial versus transfemoral approach for PCI on the outcome of patients presenting with acute coronary syndrome. This study was conducted on 100 patients presenting to Ain Shams University Hospitals Coronary Care Unit (CCU) with recent onset acute coronary syndrome (whether unstable angina (UA)/non–ST-segment-elevation MI (NSTEMI) or ST-segment-elevation MI (STEMI)) undergoing revascularization via percutaneous coronary intervention (PCI) in the period from December 2013 till December 2015. Patients were randomized into 2 equal groups, for the first group PCI was performed via transfemoral approach (TFA) while for the second group via transradial approach (TRA). Patients with cardiogenic shock or resuscitated from cardiac arrest, history of CABG or chronic kidney disease were excluded from the study. Coronary angiography and intervention procedural details were obtained in both groups including the site of culprit vessel stenosis or occlusion, presence of non-culprit diseased vessels, presence or absence of angiographic thrombus and its TIMI thrombus grade, TIMI flow prior to & after procedure, MBG scoring, and other details including type, length and diameter of stent used, balloon predilatation, thrombus aspiration, use of GP IIb/IIIa inhibitors, and procedural complications. Also some procedural details including pain-to-door (PTD) time, door-to-needle (DTN) time, door-to-balloon (DTB) time (for STEMI patients only), fluoroscopy time, amount of dye used, & access site crossover. All patients were followed up during their in-hospital stay for major adverse cardiac events (MACE), cerebrovascular stroke, major bleeding not related to access site as intracranial hemorrhage, access site complications within 48 hours after PCI using Duplex including the presence of local hematoma, retroperitoneal hematoma, pseudo-aneurysm, arterial occlusion with & without ischemia, major bleeding and the duration of hospital stay in days. Most of our studied patients were hypertensive males, 63 patients (63%) had STEMI, 32 (32%) had NSTEMI, while 5 (5%) had UA. There was no statistically significant difference between both groups regarding baseline patient characteristics but there was a significantly higher number of patients with NSTEMI in the radial group (26 (52%) versus 6 (12%)), and a higher number of patients with STEMI in the femoral group (42 (84%) versus 21 (42%)) (p < 0.0001).