Methods

We prospectively evaluated the clinical and angiographic data of 150 consecutive patients with no histories of coronary bypass grafting who underwent primary PCI for STEMI at our institution over a period of 24 months (152 procedures). All patients underwent primary PCI and were categorized into the TR access group (n = 46) or the TF access group (n = 104). The operators (n = 7) performing TF access interventions had ≥10 years of experience with PCI. The single operator using TR access had similar experience with TF access but no experience with TR access for PCI in STEMI at the onset of the study. Selection of TR or TF access for PCI was made according to operator preference. The diagnosis of STEMI was made according to the American College of Cardiology and American Heart Association guidelines.

All patients were treated with aspirin and clopidogrel (300- or 600-mg loading dose followed by 75-mg daily dose). A weight-adjusted intravenous heparin bolus (70 to 100 U/kg) was administered before PCI, titrated to a target activated clotting time of 250 to 350 seconds. In patients who received glycoprotein IIb/IIIa inhibitors (n = 80 [52.6% of the study population]), reduced heparin doses were used (50 to 70 U/kg) and again titrated to a target activated clotting time of 250 to 350 seconds. Bivalirudin was used in 2 patients (1.3%) in the study cohort. Abciximab and eptifibatide were the glycoprotein IIb/IIIa inhibitors used, depending on operator preferences. Negative results on the Allen test were considered a contraindication to the TR approach. Local anesthesia was achieved with 2% lidocaine, after which a 21-gauge angiocatheter was introduced into the radial artery using the double-wall technique. A 6Fr radial-focus TR sheath (Terumo Medical, Somerset, New Jersey) was placed in radial artery for access, and verapamil 1 mg and nitroglycerin 100 μg were given intra-arterially. At the end of the procedure, a TR band (Terumo Medical) was applied for 4 hours. Standard femoral artery access puncture was performed using an 18-gauge needle (Cook Medical, Bloomington, Indiana), after which a 6Fr sheath was introduced for access. At the end of the case, a closure device (Angioseal, St. Jude Medical, St. Paul, Minnesota; or Perclose, Abbott Vascular, Santa Clara, California) was used if access site was suitable. PCI was performed according to standard clinical practice. Successful PCI was defined according to guidelines.

Continuous variables are expressed as mean ± SD and were compared between groups using the independent-samples Student’s t test (if the normality assumption was satisfied) or Wilcoxon’s rank-sum test (if the normality assumption was violated). Categorical variables are expressed as absolute or relative frequencies and percentages and were compared between groups using Fisher’s exact test. Linear regression analysis was used to assess trends for door-to-balloon and catheterization laboratory door-to-balloon times. A significance level of 0.05 was used throughout. SAS version 9.2 (SAS Institute Inc., Cary, North Carolina) was used for all statistical calculations.

Results

The baseline clinical and demographic features of the TR and TF access groups are listed in Table 1 . There were a total of 48 interventions in the TR access group and 104 interventions in the TF access group. In the TR access group, 40 interventions (83%) were performed from the left radial approach, and 8 interventions (17%) were performed from the right radial approach. The left radial artery access was the preferred approach. In the TR access group, there was a crossover to the TF access approach in 5 interventions because of tortuous anatomy and suboptimal guiding catheter support. There were no crossovers in the TF access group. All the crossovers occurred in the first half of the study.

Catheterization laboratory door-to-balloon time and total fluoroscopy time were longer in the TR access group compared to the TF access group. However, the TR and TF access groups were comparable with respect to door-to-balloon time ( Table 2 ). The preprocedural and postprocedural Thrombolysis In Myocardial Infarction (TIMI) flow grade distribution was comparable between the TF and TR access groups. There was a trend toward a shorter duration of hospital stay in the TR access group compared to the TF access group ( Table 2 ). There were no local vascular complications or hematoma in the TR access group ( Table 3 ). In the TR access group, there was a statistically significant trend toward shorter catheterization laboratory door-to-balloon times (−0.37 minutes per additional procedure performed, p = 0.022), whereas catheterization laboratory door-to-balloon time remained unchanged in the TF group over time (+0.01 minute per additional procedure, p = 0.79) ( Figures 1 and 2 ).

Table 2

Procedures comparisons for numerical variables

Variable	Overall	TR Access	TF Access	p Value
	(n = 152)	(n = 46)	(n = 106)
Door-to-balloon time (min)				0.67
Mean ± SD	84 ± 47	79 ± 32	87 ± 52
Median (IQR)	73 (58–100)	72 (56–97)	75 (59–100)
Catheterization laboratory door-to-balloon time (min)				0.008
Mean ± SD	32 ± 13	37 ± 17	31 ± 11
Median (IQR)	29 (24–38)	34 (27–44)	29 (23–37)
Hemoglobin (g/dl)
Preintervention	14.3 ± 1.8	14.5 ± 1.9	14.2 ± 1.8	0.31
Postintervention (at 48 hours)	12.6 ± 1.7	12.9 ± 1.6	12.5 ± 1.8	0.20
Change	1.7 ± 1.3	1.7 ± 1.2	1.7 ± 1.30	0.78
Hospital stay (days)				0.112
Mean ± SD	5.3 ± 5.8	5.1 ± 7.5	5.4 ± 4.8
Median (IQR)	4 (3–5)	3 (2–5)	4 (3–5)
Fluoroscopy time (minutes)				<0.0001
Mean ± SD	17 ± 12	22 ± 13	14 ± 10
Median (IQR)	14 (9–21)	119 (15–26)	12 (8–17)
Contrast amount (ml)				0.24
Mean ± SD	178 ± 89	191 ± 102	172 ± 82
Median (IQR)	1160 (125–220)	175 (125–225)	150 (120–215)

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