Aims: This study aimed to compare outcomes in unselected patients undergoing cardiac catheterisation via transradial versus transfemoral access and standard versus ultrasound-guided arterial access.Methods and results: This was a prospective, randomised (radial vs femoral and standard vs ultrasound), 2x2 factorial trial of 1,388 patients undergoing coronary angiography and percutaneous coronary intervention. The primary outcome was a composite of ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) major bleeding, MACE (death, stroke, myocardial infarction or urgent target lesion revascularisation) and vascular complications at 30 days. Transradial access reduced the primary outcome (RR 0.37, 95% CI: 0.17-0.81; p=0.013), mostly driven by ACUITY major bleeding (RR 0.343, 95% CI: 0.123-0.959; p=0.041) when compared with the transfemoral approach. There was no difference in the primary outcome between standard and ultrasound guidance (p=0.76). Ultrasound guidance, however, reduced mean access time (93 sec vs 111 sec; p=0.009), attempts (1.47 vs 1.9; p<0.0001), difficult accesses (4.5% vs 9.2%; p=0.0007), venepuncture (4.1% vs 9.2%; p<0.0001) and improved first-pass success (73% vs 59.7%; p<0.0001).Conclusions: Transradial access significantly reduced the composite outcome compared to transfemoral access. Ultrasound guidance did not reduce the primary outcome compared to the standard technique, but significantly improved the efficiency and overall success rate of arterial access.

Background: It is unclear whether or not ultrasound-guided cannulation (UGC) of the femoral artery is superior to the standard approach (SA) in reducing vascular complications and improving access success. Objective: We sought to compare procedural and clinical outcomes of femoral UGC versus SA in patients undergoing percutaneous cardiovascular intervention (PCvI). Methods: We searched EMBASE, MEDLINE, Scopus and web sources for randomized trials comparing UGC versus SA. We estimated risk ratio (RR) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) for categorical and continuous variables, respectively. Primary efficacy endpoint was the success rate at the first attempt, while secondary efficacy endpoints were access time and number of attempts. Primary safety endpoints were the rates of vascular complications, while secondary endpoints were major bleeding, as well as access site hematoma, venepuncture, pseudoaneurysms and retroperitoneal hematoma. This meta-analysis has been registered on Centre for Open Science (OSF) (osf.io/fy82e). Results: Seven trials were included, randomizing 3180 patients to UGC (n = 1564) or SA (n = 1616). Efficacy between UGC and SA was the main metric assessed in most of the trials, in which one third of the enrolled patients underwent interventional procedures. The success rate of the first attempt was significantly higher with UGC compared to SA, (82.0% vs. 58.7%; RR: 1.36; 95% CI: 1.17 to 1.57; p < 0.0001; I2 = 88%). Time to access and number of attempts were significantly reduced with UGC compared to SA (SMD: −0.19; 95% CI: −0.28 to −0.10; p < 0.0001; I2 = 22%) and (SMD: −0.40; 95% CI: −0.58 to −0.21; p < 0.0001; I2 = 82%), respectively. Compared with SA, use of UGC was associated with a significant reduction in vascular complications (1.3% vs. 3.0%; RR: 0.48; CI 95%: 0.25 to 0.91; p = 0.02; I2 = 0%) and access-site hematoma (1.2% vs. 3.3%; RR: 0.41; CI 95%: 0.20 to 0.83; p = 0.01; I2 = 27%), but there were non-significant differences in major bleeding (0.7% vs. 1.4%; RR: 0.57; CI 95%: 0.24 to 1.32; p = 0.19; I2 = 0%). Rates of venepuncture were lower with UGC (3.6% vs. 12.1%; RR: 0.32; CI 95%: 0.20 to 0.52; p < 0.00001; I2 = 55%). Conclusion: This study, which included all available data to date, demonstrated that, compared to a standard approach, ultrasound-guided cannulation of the femoral artery is associated with lower access-related complications and higher efficacy rates. These results could be of great clinical relevance especially in the femoral cannulation of high risk patients.

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