In a large trial where patients were randomized by access site to either the femoral or the radial artery, the authors noted no difference in procedural success between approaches, while access-related complications were higher in the transfemoral group (3.71% vs. 0.58%, p = 0.0008). They did note a higher rate of access failure (3.5% vs. 0.2%, p < 0.0001) and radiation exposure (41.9 Gy cm2
vs. 38.2 Gy cm2
, p = 0.034) among the radial patients in comparison with the femoral cohort (10
). In terms of efficacy, Agostini et al. reported in a meta-analysis of 12 randomized trials that there was no difference in the rate of adverse cardiovascular events (2.1% vs. 2.4%; OR: 0.92; p = 0.7), despite a higher rate of procedural failure (7.2% vs. 2.4%; OR: 3.30; p < 0.001) between radial and femoral access strategies, respectively (11
). In terms of safety, they demonstrated less entry site complications with the radial approach (0.3% vs. 2.8%; OR: 0.2; p < 0.0001). In the US-based National Cardiovascular Data Registry (NCDR), although the overall rate of transradial PCI was low (1.32%), there was a statistically significant lower risk of bleeding complications (OR: 0.42; 95% CI: 0.31-0.56) with similar procedural success (OR: 1.02; 95% CI: 0.92-1.12) (1
). They noted that the reduction in bleeding complications was more pronounced in patients <75 years old, women and acute coronary syndrome patients.
There have been two meta-analyses that have studied the impact of access site on the treatment of acute myocardial infarction. Vorobcsuk et al. reviewed 12 prospective studies comprising 3,324 patients. Similar to prior studies of PCI, there was significantly less bleeding in the transradial group (p = 0.0001); however, they also noted a reduction in mortality (2.04% vs. 3.06%; OR: 0.54; p = 0.01) among patients in the transradial as compared with the femoral group (12
). In a subsequent analysis of only randomized trials of access site for patients undergoing primary PCI, the radial approach was associated with lower mortality (OR: 0.53; 95% CI: 0.33-0.84) and reduced vascular complications (OR: 0.35; 95% CI: 0.24-0.53) than the femoral approach (13
These observations were recently corroborated in a prospective, randomized trial. Jolly et al. reported the results of a large randomized trial of patients with acute coronary syndrome who were randomized to either radial or femoral access strategies. They observed no difference in the overall composite primary endpoint of death, myocardial infarction, stroke, or major bleeding at 30 days. However, among patients with STEMI, there was a benefit for radial over femoral access for the primary endpoint (p = 0.011) as well as for death (p = 0.001) (14
). It should be noted that operator and institutional PCI volume had an impact on outcomes.