Comparison of radial to femoral PCI in acute myocardial infarction and cardiogenic shock: a systematic review

Abstract

In randomized control trials and meta-analyses in patients with acute MI undergoing PCI, the radial artery (RA) approach compared to the femoral artery (FA) approach has shown to safely reduce access site related bleeding, length of hospitalization, and major adverse cardiac event (MACE) rates. However, these studies have excluded patients with cardiogenic shock. A systematic search was conducted to retrieve studies that investigated the safety of RA to FA PCI in patients with AMI and cardiogenic shock. Primary outcomes of interest was the pooled relative risk ratio (RR) of access site related bleeding. Secondary outcomes included (i) 30-day all cause mortality, (ii) major bleeding, (iii) final TIMI 3 flow, (iv) fluoroscopy time, and (v) amount of contrast volume administered. 6 observational studies with 7,753 patients met inclusion; 5,347 (69 %) with STEMI, 2,406 (31 %) with non-STEMI. In comparison of RA to FA PCI, there was less access site related bleeding (relative risk (RR) 0.11, p = 0.001), less 30-day mortality (RR 0.65, p = 0.0 < 0.001), and less major bleeding (RR of 0.46 p < 0.0001). There was no significant difference in final TIMI 3 flow (p = 0.27), fluoroscopy time (p = 0.95), and contrast volume administered (p = 0.59). In conclution, despite its limitations, our analysis demonstrates an association towards lower adverse events in the RA PCI group. Although we believe that the choice of access site in a high-risk setting should be at the operator discretion, if technically feasible, the RA appears to be a reasonable vascular access approach in high-risk patients in cardiogenic shock.

Radial approach reduces mortality in ST-segment elevation myocardial infarction with cardiogenic shock

“…To our best knowledge, the presented study for the first time provides a clinical view from a national perspective on the impact of vascular access site on clinical outcomes in STEMI with CS in a contemporary unselected cohort of patients. Our analysis is consistent with the results of former studies [11,[19][20][21][22][23][24]. Favorable outcome in RA was confirmed in a large meta-analysis of 6 observational studies [11].…”

“…Our analysis is consistent with the results of former studies [11,[19][20][21][22][23][24]. Favorable outcome in RA was confirmed in a large meta-analysis of 6 observational studies [11]. However, the metaanalysis included observational and retrospective studies.…”

“…However, the metaanalysis included observational and retrospective studies. Thus, results might not entail causation or a treatment effect [11]. Furthermore, enrollment of STEMI and non-ST segment elevation myocardial infarction (NSTEMI) with blood pressure threshold <100 mmHg rather than most commonly used <90 mmHg for CS definition might limit the generalizability of the results [11,24].…”

“…Thus, results might not entail causation or a treatment effect [11]. Furthermore, enrollment of STEMI and non-ST segment elevation myocardial infarction (NSTEMI) with blood pressure threshold <100 mmHg rather than most commonly used <90 mmHg for CS definition might limit the generalizability of the results [11,24]. Only two small retrospective studies confirmed no difference in short-term outcomes between RA and FA in STEMI complicated by CS [25,26].…”

“…The absence of a radial pulse is the most common reason for choosing FA in those patients. Thus, RA utilization in STEMI complicated by CS was scarcely evaluated [9][10][11][12]. There is paucity in evidence since randomized comparison might not be feasible due to impaired consciousness and the equivocal ability for patient consent in this clinical setting.…”