I read the article published by Cortese et al. This Italian registry of primary percutaneous coronary intervention has recognized the favorable impact of transradial access in reduction of acute kidney injury; besides well-known predisposing condition as underlying kidney dysfunction and the amount of contrast used during percutaneous intervention, investigators underscored that transfemoral access and Thrombolysis In Myocardial Infarction bleedings (major and minor) are other independent predictors of postprocedural renal complication.

Such negative effect of transfemoral compared with transradial access may be related to hypothetic renal atherothrombotic embolism during retrograde thoracoabdominal aortic catheterization, although overall bleedings occurring during acute phase of myocardial infarction (both access and not access related, also amplified by administrated intravenous antithrombotic therapy) could determine renal injury through hypovolemic status and consequent cortical glomerular hypoperfusion.

Investigators came to this intriguing conclusion after a propensity score analysis in which 2 groups were well-matched for most important demographical, clinical, and procedural variables; however, before matching analysis, the use of bivalirudin in transradial group was significantly superior compared with transfemoral group (18.4% vs 3%, p value <0.001), but this determinant variable was not included during propensity score analysis.

It is well demonstrated in previous randomized multicenter studies and recent meta-analysis the beneficial effect during primary percutaneous coronary intervention of administration of bivalirudin (vs unfractionated heparin plus provisional use of glycoprotein IIb/IIIa inhibitor) in terms of reduction of net adverse clinical events, including all major bleedings, even determining a favorable immediate and long-term outcomes.

Finally, between 2 matched groups analysis, Cortese et al registered a significant acute kidney injury reduction (primary end point) in transradial group (8.4% vs 16.9%, p = 0.007) and Thrombolysis In Myocardial Infarction major bleedings (0.3% vs 3%, p = 0.03; secondary end point) although no statistical difference emerged among common major adverse cardiac events and stent thrombosis. Therefore, it cannot be excluded an adjunctive role of bivalirudin to transradial primary percutaneous coronary intervention in lowering incidence of acute kidney injury through in-hospital reduction of overall major hemorrhagic events.