1
Brief report/letter
Compared with femoral access, percutaneous coronary intervention (PCI) via radial access is associated with decreased vascular access site bleeding complications, reduced hospital length of stay and cost and increased patient satisfaction . Despite these benefits, uptake of transradial PCI (TRI) has been slow in the United States . The majority of PCIs occur in the same session as the diagnostic coronary angiogram ( ad hoc PCI) . In many practice settings, non-interventional operators frequently perform diagnostic coronary angiography, and the choice of initial vascular access by a non-interventional operator may therefore influence rates of transradial PCI (TRI). In this brief report, we sought to determine the relationship between operator type and choice of initial vascular access to rates of TRI.
2
Methods
Using data from the Department of Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all VA patients who underwent ad hoc PCI (diagnostic coronary angiography and PCI performed on the same day) from July 2008 through September 2012. To ensure patients had an opportunity to receive TRI, our primary analysis excluded facilities performing less than 5% TRI. All tests were 2-tailed, with a two-sided alpha of 0.05. We compared patient characteristics by non-interventional vs. interventional operator type obtaining initial access using Pearson chi-square tests for categorical variables and Mann–Whitney Wilcoxon non-parametric tests for continuous variables. We compared rates of TRI by operator type using Pearson chi-squared tests.
2
Methods
Using data from the Department of Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all VA patients who underwent ad hoc PCI (diagnostic coronary angiography and PCI performed on the same day) from July 2008 through September 2012. To ensure patients had an opportunity to receive TRI, our primary analysis excluded facilities performing less than 5% TRI. All tests were 2-tailed, with a two-sided alpha of 0.05. We compared patient characteristics by non-interventional vs. interventional operator type obtaining initial access using Pearson chi-square tests for categorical variables and Mann–Whitney Wilcoxon non-parametric tests for continuous variables. We compared rates of TRI by operator type using Pearson chi-squared tests.
3
Results
Among 11,952 patients who underwent ad hoc PCI, 1,317 (11%) had initial access obtained by a non-interventional operator. Ad hoc PCI patients with initial access obtained by an interventionalist were more likely to present with ST-segment elevation myocardial infarction (8.4% vs. 4.7%, p < 0.001) and have three-vessel coronary artery disease (24.4% vs. 19.8%, p < 0.001)( Table 1 ). The percent of non-interventionalists at each site ranged from 0 to 100% with a median of 20% per site. Compared with patients whose vascular access was obtained by an interventionalist, patients with access obtained by a non-interventionalist were less likely to undergo radial access (18.5% vs. 27.1%, p < 0.001) ( Table 2 ).
| All patients (N = 11952) | Non interventionalist (N = 1317) | Interventionalist (N = 10635) | P-value | |
|---|---|---|---|---|
| Demographics | ||||
| Age, median (IQR) | 63.70 (59.30, 69.60) | 63.80 (59.50, 69.30) | 63.70 (59.30, 69.60) | 0.441 |
| Male | 11740 | 1294 (98.25%) | 10446 (98.22%) | 0.999 |
| White | 10131 | 1139 (86.48%) | 8992 (84.55%) | 0.067 |
| Prior coronary history | ||||
| Prior MI | 4573 | 426 (32.35%) | 4147 (38.99%) | < 0.001 |
| Prior PCI | 6921 | 764 (58.01%) | 6157 (57.89%) | 0.953 |
| Prior CABG | 3252 | 278 (21.11%) | 2974 (27.96%) | < 0.001 |
| Risk factor & comorbidities | ||||
| History of smoking | 8310 | 891 (67.65%) | 7419 (69.76%) | 0.12 |
| Diabetes | 5707 | 587 (44.57%) | 5120 (48.14%) | 0.015 |
| Hypertension | 10918 | 1175 (89.22%) | 9743 (91.61%) | 0.004 |
| Hyperlipidemia | 10854 | 1174 (89.14%) | 9680 (91.02%) | 0.03 |
| Peripheral vascular disease | 2918 | 261 (19.82%) | 2657 (24.98%) | < 0.001 |
| Cerebrovascular disease | 2331 | 256 (19.44%) | 2075 (19.51%) | 0.971 |
| COPD | 2779 | 312 (23.69%) | 2467 (23.20%) | 0.704 |
| Obese | 4478 | 442 (33.56%) | 4036 (37.95%) | 0.002 |
| Overweight | 3255 | 295 (22.40%) | 2960 (27.83%) | < 0.001 |
| Dialysis | 297 | 22 (1.67%) | 275 (2.59%) | 0.048 |
| CKD (non-dialysis) | 2102 | 183 (13.90%) | 1919 (18.04%) | < 0.001 |
| Depression | 4477 | 481 (36.52%) | 3996 (37.57%) | 0.469 |
| Framingham risk | ||||
| Low | 2012 | 234 (17.77%) | 1778 (16.72%) | 0.349 |
| Intermediate | 6762 | 750 (56.95%) | 6012 (56.53%) | 0.791 |
| High | 3178 | 333 (25.28%) | 2845 (26.75%) | 0.261 |
| Procedural indication | ||||
| STEMI | 954 | 62 (4.71%) | 892 (8.39%) | < 0.001 |
| NSTEMI | 2432 | 281 (21.34%) | 2151 (20.23%) | 0.346 |
| Unstable angina | 3195 | 306 (23.23%) | 2889 (27.17%) | 0.002 |
| Stable angina | 3382 | 328 (24.91%) | 3054 (28.72%) | 0.004 |
| Chest pain | 5016 | 591 (44.87%) | 4425 (41.61%) | 0.024 |
| Ischemic heart disease | 870 | 86 (6.53%) | 784 (7.37%) | 0.286 |
| Abnormal functional study | 703 | 69 (5.24%) | 634 (5.96%) | 0.321 |
| Cardiomyopathy | 69 | 21 (1.59%) | 48 (0.45%) | < 0.001 |
| Valvular heart disease | 40 | 3 (0.23%) | 37 (0.35%) | 0.618 |
| Other indication | 5609 | 621 (47.15%) | 4988 (46.90%) | 0.884 |
| Angiographic findings | ||||
| Normal | 5 | 2 (0.15%) | 3 (0.03%) | 0.097 |
| Obstructive CAD | ||||
| One-vessel CAD | 5147 | 630 (47.84%) | 4517 (42.47%) | < 0.001 |
| Two-vessel CAD | 3355 | 375 (28.47%) | 2980 (28.02%) | 0.745 |
| Three-vessel CAD | 2854 | 261 (19.82%) | 2593 (24.38%) | < 0.001 |
| Unknown | 67 | 5 (0.38%) | 62 (0.58%) | 0.437 |
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