Patients undergoing PCI from the femoral route by default radial operators are at high risk of vascular access-site complications

Selected in EuroIntervention Journal by S. Brugaletta

References

Reference

EuroIntervention 2014;9: 1189-1194

Published

February 2014

Link

Access article

Aims 

Radial artery (RA) access for PCI has a lower incidence of vascular access-site (VAS) complications than the femoral artery (FA) approach. However, even for default radial operators certain patients are intervened upon from the FA. We examined the demographics and incidence of VAS complications when default radial operators resort to the FA for PCI.

Methods and results  

The demographics and VAS complications were compared by access site retrospectively for all PCI cases performed by default radial operators (n=1,392). A modified ACUITY trial definition of major VAS complication was used. FA puncture occurred in 25.2% (351/1,392) of cases. Patients were more likely to be female, older and weigh less than patients undergoing PCI from the RA. The FA procedure was likely to be more complex with larger sheaths, more left main stem, graft and multivessel intervention, and there was a greater proportion of emergency cases. Despite increased case complexity, glycoprotein inhibitors were used less frequently in femoral cases (26.5% vs. 36.8%, p<0.001). A VAS complication occurred in 12.5% (44/351) of cases.

Conclusions 

The risk factors for access-site bleeding are disproportionately high in the population requiring FA puncture by default radial operators, and as a result such patients have a high rate of vascular access-site complications.

My Comment

What is known  

Percutaneous coronary intervention (PCI) performed via the radial route is increasingly the preferred choice among interventional cardiologists worldwide. Over the last two decades, radial access has transformed from being the “alternative” approach, used only if the femoral route was contraindicated, to the “primary” choice. However, the radial approach has several known limitations. The radial artery diameter will often limit the use of large sheath sizes, although the use of sheathless guides and downsizing of equipment have reduced the need for femoral bail-out. In addition, the radial artery may be very difficult to cannulate in shocked patients or indeed negotiate because of tortuosity, radial loops and intense vasospasm. Therefore, a default radial operator, driven either by necessity or choice, may default to the femoral approach in a proportion of patients. The present study analyzed the vascular site complications in a patient population requiring a femoral artery puncture by default radial operators.

Major findings 

  • Out of a historical cohort of 1392 patients, femoral puncture occurred in 25.2%
  • Patients were more likely to be female, older and weigh less than patients undergoing PCI from the radial access.
  • The FA procedure was likely to be more complex with larger sheaths, more left main stem, graft and multivessel intervention, and there was a greater proportion of emergency cases.
  • Despite increased case complexity, glycoprotein inhibitors were used less frequently in femoral cases (26.5% vs. 36.8%, p<0.001).
  • A vascular access site complication occurred in 12.5% (44/351) of femoral cases.

My comments 

This is an interesting analysis on femoral site complications in patients who have undergone PCI by radial operators. The paper is limited by the lack of a control group, showing femoral site complications by operators experienced in femoral approach, and by the lack of a multivariate analysis taking into account the variable “operator”. In any case it is interesting to see a very high rate of vascular complications in these femoral patients and although many clinical or procedural factors could be taken into account, the variable operator should be considered. It is important to consider that in an interventional cardiology era of radialists, vascular site complications at femoral site are destined to increase. This fact should be considered in the training of young fellows.  

3 comments

  • Lorenzo Azzalini 05 Mar 2014

    Despite several methodological limitations, this study confirms the concern that - with increased radial access exposure (in some centers the prevalence is as high as 90%) - young operators are not comfortable with obtaining the femoral access in a safe fashion. And this is even more worrisome if we consider that, as it is shown in the study, femoral access in Europe is nowadays performed especially in complex cases at high risk for an access-site related complication.

  • karthikeyan ganesan 13 May 2014

    This finding may be valid for those operators whose first and only experience is through radial access unlike other somewhat older and longer experienced operators who were initially using femoral access and later on switched to radial procedures and they will certainly retain the practical experience of femoral access management without excess bleeding complications Ganesan Karthikeyan, chennai, India

  • Salvatore Brugaletta 28 May 2014

    I agree with you Karthikeyan. Do you think that training program for fellows should include a period of femoral access training?