Trends in Arterial Access Site Selection and Bleeding Outcomes Following Coronary Procedures, 2011–2018

Abstract

Background: Prior studies of radial access for cardiac catheterization have focused on early adopters of the technique, and some have described a risk/treatment paradox of low radial access use among high bleeding risk patients. This study aimed to determine (1) trends in radial access use over time, (2) if increasing use of radial access is driven by new invasive and interventional cardiologists (operators) or existing operators changing their practice, and (3) if increasing radial rates are associated with lower bleeding rates and elimination of the risk/treatment paradox. Methods: In this cross-sectional study using data from the Clinical Assessment, Reporting, and Tracking Program, we calculated radial access rates and risk-adjusted postprocedural bleeding rates of patients undergoing diagnostic angiography or percutaneous coronary intervention (PCI) between 2011 and 2018 in Veterans Affairs hospitals. We used separate bleeding risk models for diagnostic angiography and PCI and assessed temporal trends with the Kendall Tau-b test. Results: Among 253 179 diagnostic angiograms and 93 614 PCIs, radial access rates increased over time for both diagnostic (17.5%–60.4%; P <0.01)) and PCI procedures (14.0%–51.8%; P <0.01). Existing operators and new operators increased their use at similar rates, but new operators entered practice with higher baseline rates. Nearly all operators used radial access at least once in 2018. Overall adjusted rates of bleeding declined, a trend that was significant for diagnostic angiography (2.4%–1.4%, P =0.02) but not PCI (3.4%–2.5%, P =0.20). Femoral access patients had a higher predicted risk for bleeding. Conclusions: A steady rise in radial access for diagnostic angiography and PCI was driven by increasing use among existing operators and high use by new operators. While this was associated with decreasing bleeding rates, a risk/treatment paradox for access site selection persists; patients at higher bleeding risk were still more likely to receive femoral access.

Distal Versus Conventional Radial Access for Coronary Angiography and Intervention

“…6 Yet the adoption rate of TRA varies across countries, with some significant room for growth. 7 Anatomical constraints may limit the clinical benefits of TRA, yielding a few complications, including radial artery occlusion (RAO), a complex process involving several interplaying factors ultimately leading to thrombosis. RAO is by far the most frequent complication of TRA, with highest incidence in the first 24 hours and spontaneous recanalization at 30 days in about one-half of the patients.…”

Traditional versus distal radial access for coronary angiography: a meta-analysis of randomized controlled trials

“…Percutaneous coronary procedures were traditionally accessed through the femoral artery [1]. In the last 2 decades, many randomized controlled trials (RCTs) have shown a significant benefit of transradial over transfemoral access, including those who required complex coronary intervention [1][2][3][4]. Traditional radial access in the forearm was associated with lower mortality, major bleeding, and access site complications, without compromising procedural success [1][2][3][4][5].…”

“…In the last 2 decades, many randomized controlled trials (RCTs) have shown a significant benefit of transradial over transfemoral access, including those who required complex coronary intervention [1][2][3][4]. Traditional radial access in the forearm was associated with lower mortality, major bleeding, and access site complications, without compromising procedural success [1][2][3][4][5]. Because of these pertinent advantages, the American College of Cardiology/ American Heart Association/Society for Cardiovascular Angiography and Interventions guidelines have recommended transradial over transfemoral approach in patients undergoing percutaneous coronary intervention (PCI) for both acute coronary syndrome (ACS) and stable ischemic heart disease, (class of recommendation: I, level of evidence: A) [2].…”

“…The most important complication is radial artery occlusion (RAO) in up to 5% of patients [6,7]. Although adverse ischemic sequelae are rare due to extensive anastomosis distal to the wrist, the occluded radial artery will limit its use for future coronary and noncoronary procedures such as coronary bypass grafting or creating a hemodialysis arteriovenous fistula [1]. Recently, the distal radial artery (DRA) in the anatomical snuff box has emerged as a novel access for coronary interventions with potentially lower RAO events.…”

“…Percutaneous coronary procedures were traditionally accessed through the femoral artery [1]. In the last 2 decades, many randomized controlled trials (RCTs) have shown a significant benefit of transradial over transfemoral access, including those who required complex coronary intervention [1][2][3][4].…”