Radial Versus Femoral Access in Chronic Total Occlusion Percutaneous Coronary Intervention

Abstract

Background: Radial access (RA) is increasingly used in chronic total occlusion (CTO) percutaneous coronary intervention with encouraging results. However, there are concerns about its safety and efficacy because of higher complexity and the need for strong guide catheter support. Methods and Results: We performed a systematic review and meta-analysis of all studies published through November 2018 reporting the outcomes of RA versus femoral access in CTO percutaneous coronary intervention. Outcomes included major bleeding, access-site complications, in-hospital major adverse events, and technical success. Nine observational studies with 10 590 patients (10 617 lesions) were included in the meta-analysis. CTO lesions attempted using RA had lower Japan-CTO score (2.3±1.2 versus 2.5±1.3; P <0.001). Use of RA was associated with similar technical success (78.7% versus 78.5%; odds ratio, 1.11; 95% CI, 0.94–1.31; P =0.24; I 2 =23%), lower risk of access-site complications (0.73% versus 1.79%; odds ratio, 0.34; 95% CI, 0.22–0.51; P <0.001; I 2 =0%) and major bleeding (0.18% versus 0.9%; odds ratio, 0.22; 95% CI, 0.10–0.45; P <0.001; I 2 =0%), and similar risk of in-hospital adverse events and in-hospital mortality (odds ratio, 0.36; 95% CI, 0.12–1.07; P =0.07; I 2 =0%) as compared to femoral access. Results were similar when analyzing radial-only versus any femoral access and when excluding the largest study. Conclusions: As compared with femoral access, RA is used in CTO percutaneous coronary intervention of less complex lesions and is associated with fewer access-site complications and major bleeding and comparable technical success.

Outcomes with retrograde versus antegrade chronic total occlusion revascularization

“…Nevertheless, the retrograde approach should only be used when the perceived benefits outweigh the potential risks. Performance of retrograde CTO PCI by experienced operators who can identify and treat complications early and are attentive to the need for stent optimization, 45 as well as using approaches that help reduce complications like the radial approach, 46 could improve the outcomes of retrograde CTO PCI.…”

SCAI position statement on optimal percutaneous coronary interventional therapy for complex coronary artery disease

“…[78][79][80] Complex interventions including LM bifurcations, CTO PCI, and large burr atherectomy may now be performed safely and effectively via the radial artery with standard or sheathless guide catheters up to eight French in size, and incorporating additional support strategies that include guide catheter extensions and anchor balloons. 79,81 Evidence also suggests that when necessary, femoral access may still be performed safely by expert operators using optimal ultrasound-guided access, including the use of micropuncture needles. [82][83][84][85] Multiple arterial access sites are often needed for CTO PCI or adjunctive MCS device use during complex PCI, thereby increasing the periprocedural risks of bleeding, vascular complications, and mortality.…”

“…86 These hazards may be mitigated by the use of radial or ulnar artery access as the second-access site, bilateral radial access, or single-access femoral techniques for MCS-assisted PCI. 79,87,88 Radial access with newer dedicated long-shaft peripheral equipment may also be effective in both obtaining hemostasis and resolving complications during large-bore femoral access. 89 (e.g., retrograde CTO PCI).…”

“…Radial access is associated with similar technical and procedural success compared to femoral access and often offers lower risks of major bleeding and vascular complications 78‐80 . Complex interventions including LM bifurcations, CTO PCI, and large burr atherectomy may now be performed safely and effectively via the radial artery with standard or sheathless guide catheters up to eight French in size, and incorporating additional support strategies that include guide catheter extensions and anchor balloons 79,81 . Evidence also suggests that when necessary, femoral access may still be performed safely by expert operators using optimal ultrasound‐guided access, including the use of micropuncture needles 82‐85 …”

“…Multiple arterial access sites are often needed for CTO PCI or adjunctive MCS device use during complex PCI, thereby increasing the periprocedural risks of bleeding, vascular complications, and mortality 86 . These hazards may be mitigated by the use of radial or ulnar artery access as the second‐access site, bilateral radial access, or single‐access femoral techniques for MCS‐assisted PCI 79,87,88 . Radial access with newer dedicated long‐shaft peripheral equipment may also be effective in both obtaining hemostasis and resolving complications during large‐bore femoral access 89 .…”