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Radial Versus Femoral Access in Invasively Managed Patients With Acute Coronary Syndrome: A Systematic Review and Meta-analysisRadial Access in Acute Coronary Syndromes

Giuseppe Andò, MD, PhD; and Davide Capodanno, MD, PhD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 10 November 2015.


From the University of Messina, Messina, and Ferrarotto Hospital, University of Catania, Catania, Italy.

Grant Support: The authors are funded by their academic institutions.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1277.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Andò (giuseppe.ando@unime.it or giuseppeando1975@gmail.com).

Requests for Single Reprints: Giuseppe Andò, MD, PhD, Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, c/o Azienda Ospedaliera Universitaria Policlinico “Gaetano Martino,” Via Consolare Valeria, 98124 Messina, Italy; e-mail, giuseppe.ando@unime.it or giuseppeando1975@gmail.com.

Current Author Addresses: Dr. Andò: Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, c/o Azienda Ospedaliera Universitaria Policlinico “Gaetano Martino,” Via Consolare Valeria, 98124 Messina, Italy.

Professor Capodanno: Department of General Surgery and Medical-Surgical Specialties, University of Catania, c/o Ospedale Ferrarotto, Via Salvatore Citelli 31, 95124 Catania, Italy.

Author Contributions: Conception and design: G. Andò.

Analysis and interpretation of the data: G. Andò, D. Capodanno.

Drafting of the article: G. Andò, D. Capodanno.

Critical revision of the article for important intellectual content: D. Capodanno.

Final approval of the article: G. Andò, D. Capodanno.

Statistical expertise: G. Andò.

Collection and assembly of data: G. Andò.


Ann Intern Med. 2015;163(12):932-940. doi:10.7326/M15-1277
Text Size: A A A

Background: Studies in patients with acute coronary syndrome (ACS) undergoing invasive management showed conflicting conclusions regarding the effect of access site on outcomes.

Purpose: To summarize evidence from recent, high-quality trials that compared clinical outcomes occurring with radial versus femoral access in invasively managed adults with ACS.

Data Sources: English-language publications in MEDLINE, EMBASE, and Cochrane databases between January 1990 and August 2015.

Study Selection: Randomized trials of radial versus femoral access in invasively managed patients with ACS.

Data Extraction: Two investigators independently extracted the study data and rated the risk of bias.

Data Synthesis: Of 17 identified randomized trials, 4 were high-quality multicenter trials that involved a total of 17 133 patients. Pooled data from the 4 trials showed that radial access reduced death (relative risk [RR], 0.73 [95% CI, 0.59 to 0.90]; P = 0.003), major adverse cardiovascular events (RR, 0.86 [CI, 0.75 to 0.98]; P = 0.025), and major bleeding (RR, 0.57 [CI, 0.37 to 0.88]; P = 0.011). Radial procedures lasted slightly longer (standardized mean difference, 0.11 minutes) and had higher risk for access-site crossover (6.3% vs. 1.7%) than did femoral procedures.

Limitation: Heterogeneity in outcomes definitions and potential treatment modifiers across studies, including operator experience in radial procedures and concurrent anticoagulant regimens.

Conclusion: Compared with femoral access, radial access reduces mortality, major adverse cardiovascular events, and major bleeding in patients with ACS undergoing invasive management.

Primary Funding Source: None. (PROSPERO registration number: CRD42015022031)

Figures

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Figure 1.

Summary of evidence search and selection.

Selection process for studies to be included in the meta-analysis in compliance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards.

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Appendix Figure 1.

Risk of bias in the studies included in the meta-analysis.

Plus sign denotes low risk. Minus sign denotes high risk. MATRIX = Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX; RIFLE-STEACS = Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome; RIVAL = A Trial of Trans-radial Versus Trans-femoral Percutaneous Coronary Intervention Access Site Approach in Patients With Unstable Angina or Myocardial Infarction Managed With an Invasive Strategy; STEMI-RADIAL = Trial Comparing Radial and Femoral Approach in Primary Percutaneous Coronary Intervention.

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Appendix Figure 2.

Meta-analysis of radial versus femoral access for access-site crossover.

MATRIX = Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX; RIFLE-STEACS = Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome; RIVAL = A Trial of Trans-radial Versus Trans-femoral Percutaneous Coronary Intervention Access Site Approach in Patients With Unstable Angina or Myocardial Infarction Managed With an Invasive Strategy; RR = relative risk; STEMI-RADIAL = Trial Comparing Radial and Femoral Approach in Primary Percutaneous Coronary Intervention; W = weight.

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Figure 2.

Meta-analysis of radial versus femoral access for all-cause mortality and MACE.

The forest plots show a 27% RR reduction in mortality and a 14% RR reduction in MACE with radial compared with femoral access. MACE = major adverse cardiovascular events; MATRIX = Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX; RIFLE-STEACS = Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome; RIVAL = A Trial of Trans-radial Versus Trans-femoral Percutaneous Coronary Intervention Access Site Approach in Patients With Unstable Angina or Myocardial Infarction Managed With an Invasive Strategy; RR = relative risk; STEMI-RADIAL = Trial Comparing Radial and Femoral Approach in Primary Percutaneous Coronary Intervention; W = weight.

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Figure 3.

Meta-analysis of radial versus femoral access for access-site and major bleeding.

The forest plots show a 64% RR reduction in access-site bleeding and a 43% RR reduction in major bleeding with radial compared with femoral access. MATRIX = Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX; RIFLE-STEACS = Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome; RIVAL = A Trial of Trans-radial Versus Trans-femoral Percutaneous Coronary Intervention Access Site Approach in Patients With Unstable Angina or Myocardial Infarction Managed With an Invasive Strategy; RR = relative risk; STEMI-RADIAL = Trial Comparing Radial and Femoral Approach in Primary Percutaneous Coronary Intervention; W = weight.

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Appendix Figure 3.

Meta-analysis of radial versus femoral access for myocardial infarction and stroke.

MATRIX = Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX; RIFLE-STEACS = Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome; RIVAL = A Trial of Trans-radial Versus Trans-femoral Percutaneous Coronary Intervention Access Site Approach in Patients With Unstable Angina or Myocardial Infarction Managed With an Invasive Strategy; RR = relative risk; STEMI-RADIAL = Trial Comparing Radial and Femoral Approach in Primary Percutaneous Coronary Intervention; W = weight.

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