Impact of Arterial Access Site on Outcomes After Primary Percutaneous Coronary Intervention

Abstract

Background-In European Ambulance Acute Coronary Syndrome Angiography (EUROMAX), bivalirudin improved 30-day clinical outcomes with reduced major bleeding compared with heparins plus optional glycoprotein IIb/IIIa inhibitors. We assessed whether choice of access site (radial or femoral) had an impact on 30-day outcomes and whether it interacted with the benefit of bivalirudin. Methods and Results-In EUROMAX, choice of arterial access was left to operator discretion. Overall, 47% of patients underwent radial and 53% femoral access. Baseline risk was higher in the femoral access group. Unadjusted proportions for the primary outcome (death or noncoronary artery bypass graft protocol major bleeding at 30 days) were lower with radial access, however, without differences in major or major plus minor bleeding proportions. After multivariable adjustment, ischemic outcomes were no longer different between access site groups, except for a lower risk of stroke in radial patients. Bivalirudin was associated with lower proportions of the primary outcome in both the radial (odds ratio, 0.58; 95% CI, 0.33-1.03; P=0.058) and the femoral groups (odds ratio, 0.59; 95% CI, 0.37-0.93; P=0.022; interaction P=0.97). Bleeding was significantly lower in the bivalirudin group both in the radial-and femoral-treated patients but no significant difference was observed in ischemic outcomes. In multivariable analysis, bivalirudin emerged as the only independent predictor of reduced major bleeding (odds ratio, 0.45; 95% CI, 0.27-0.74; P=0.002). Conclusions-In this prespecified analysis from EUROMAX, radial access was preferred in lower risk patients and did not improve clinical outcomes. Bivalirudin was associated with less bleeding irrespective of access site. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01087723.(Circ Cardiovasc Interv. 2015;8:e002049.

Relationship Between Arterial Access and Outcomes in ST‐Elevation Myocardial Infarction With a Pharmacoinvasive Versus Primary Percutaneous Coronary Intervention Strategy: Insights From the STrategic Reperfusion Early After Myocardial Infarction (STREAM) Study

“…The utilization of radial (RA) over femoral arterial access (FA) for acute coronary intervention in ST‐elevation myocardial infarction (STEMI) is supported by a reduction in mortality, ischemic, and bleeding endpoints 1, 2, 3, 4, 5, 6, 7, 8. This has led various interventional societies to encourage its utilization over femoral access 9, 10, 11.…”

Is It Time to Join the Cult?

“…A multivariable risk model indicated that bivalirudin was a predictor of bleeding risk, whereas access site was not. 14 These results stand in contradistinction with those of the large randomized trials that have shown TRA to be more effective than TFA. 5,13 Although it is easy to dismiss them as observations now that powerful randomized data are available, that view would be mistaken.…”

“…In the current issue of Circulation: Cardiovascular Interventions, Hamon et al 14 provide an intriguing and refreshing, if different, perspective. Their observations are taken from the EUROMAX (European Ambulance Acute Coronary Syndrome Angiography) trial of bivalirudin versus heparin begun before primary PCI in patients with ST-segmentelevation myocardial infarction, performed between 2010 and 2013.…”

“…The authors speculate that differential patient selection for trials of pharmacotherapy compared with trials of access site may have played a role. Another possible factor is the differential use of glycoprotein IIb-IIIa antagonists: 30% in the study by Hamon et al 14 versus 12% in MATRIX Access. 5 Alternatively, experienced TRA operators may have become good at discerning which patients were likely to benefit from TRA versus TFA.…”

The impact of unfractionated heparin or bivalirudin on patients with stable coronary artery disease undergoing percutaneous coronary intervention

“…Radial access significantly reduced net clinical events by way of lower all‐cause mortality and major bleeding . Additionally, other contemporary trials have reported on the impact of access sites in patients undergoing primary PCI . The aim of the present study was to compare bivalirudin with UFH in patients with stable CAD undergoing PCI on dual anti‐platelet therapy (DAPT).…”