Transradial access in acute myocardial infarction complicated by cardiogenic shock: Stratified analysis by shock severity

Abstract

Background Transradial access (TRA) is associated with improved survival and reduced vascular complications in acute myocardial infarction (AMI). Limited data exist regarding TRA utilization and outcomes for AMI complicated by cardiogenic shock (CS). We sought to assess the safety, feasibility, and clinical outcomes of TRA in AMI‐CS. Methods One‐hundred and fifty‐three patients with AMI‐CS were stratified into tertiles of disease severity using the CardShock score. The primary endpoint was successful percutaneous coronary intervention (PCI), defined as Thrombolysis in Myocardial Infarction III flow with survival to 30 days. Results Mean age was 66 years, 72% were men, and 47% had diabetes. TRA was the preferred access site in patients with low and intermediate disease severity. Overall, 50 (32%) patients experienced major adverse cardiac and cerebrovascular events; most events (78%) occurred in patients undergoing transfemoral access (TFA) in the intermediate‐high tertiles of CS severity. Of the 41 (27%) total bleeding events, 32% occurred at the coronary angiography access site, of which 92% were in the TFA group. The use of ultrasound (US) guidance for TFA resulted in reduced coronary access‐site bleeding (8.5 vs. 33.0%, p = .01). In a hierarchical logistic regression model, utilizing TRA did not result in lower odds of successful PCI (Odds ratio [OR]: 1.36; 95% confidence interval [CI]: 0.54–3.40). Conclusion This study suggests that TRA is feasible across the entire spectrum of AMI‐CS and is associated with reduced coronary access‐site bleeding. In addition, US‐guided TFA is associated with reductions in access‐site bleeding and vascular complications. Concerted efforts should be made to incorporate vascular access protocols into existing CS algorithms in dedicated shock care centers.

Acute myocardial infarction related cardiogenic shock: How important is vascular access site?

“…Although, it is difficult to argue with prior randomized trials showing reduced bleeding and improved mortality with radial access in the AMI population, a more recent randomized trial of >2000 AMI patients from North America showed minimal differences in outcomes between radial and femoral arms 5 . Importantly, the highly significant, four‐fold improvement in access site bleeding and vascular complications observed with ultrasound guided femoral access in the current study, 1 is reassuring that use of the femoral artery for cardiogenic shock interventions remains a reasonable alternative, if meticulous care is given to access technique.…”

“…In this issue of the journal, Tehrani et al reported a retrospective study of 153 patients with acute myocardial infarction (AMI) associated cardiogenic shock (CS) treated at a single high volume shock center 1 . Radial access for coronary angiography was used in 53%, and usually applied to patients with less severe CS.…”

Lies, damned lies, and statistics, but bleeding and acute limb ischemia are facts!

“…Acute ischemic limbs and major vascular complications during cardiogenic shock admission were as high as 10%, which led to accelerated development of short-and long-term adverse outcomes. 5 Despite this variability in the estimates, which could be explained by a large heterogeneous study population, variability in the definition of exposures and outcome inherent to claims datasets, and the application of causal inference techniques, this study highlights an important fact: bleeding and vascular injury remain an important outcome in interventional cardiology, but even more for those with cardiogenic shock. Because significant variability in care for cardiogenic shock exists in practice within different regions of the United States and worldwide, several initiatives by academic consortiums, endorsed by the Food and Drug Administration (FDA), are actively engaged to address clinical problems that have a large impact on outcomes in patients with cardiogenic shock.…”

“…Similarly, in an observational study, one in three patients develop major bleeding events secondary to large‐bore access used for mechanical circulatory support devices. Acute ischemic limbs and major vascular complications during cardiogenic shock admission were as high as 10%, which led to accelerated development of short‐ and long‐term adverse outcomes 5 …”

Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

“…139 In contemporary practice, bleeding risk is reduced by the use of radial access, even among patients presenting with cardiogenic shock. 148,149 Bleeding risk is further reduced with the use of the latest generation drug-eluting stents and shorter duration of DAPT. 150,151 The SENIOR trial showed that in older adults with high bleeding risk, patients treated with drug-eluting stents and short-duration DAPT had a lower incidence of the composite end point of all-cause death‚ MI, stroke, or urgent revascularization compared with patients treated with bare-metal stents and short-duration DAPT with no difference in risk of bleeding.…”