Short-term risk of periprocedural stroke relative to radial vs. femoral access: systematic review, meta-analysis, study sequential analysis and meta-regression of 2,188,047 real-world cardiac catheterizations

ABSTRACT

Objectives

To verify whether transradial (TRA) compared to transfemoral (TFA) cardiac catheterization reduces the risk of periprocedural stroke (PS).

Methods

We reviewed (CRD42021277918) published real-world cohorts reporting the incidence of PS within 3 days following diagnostic or interventional catheterization. Meta-analyses and meta-regressions of odds ratios (OR) performed using the DerSimonian and Laird method were checked for publication bias (Egger test) and adjusted for false-positive results (study sequential analysis SSA).

Results

The pooled incidence of PS from 2,188,047 catheterizations (14 cohorts), was 193 (105 to 355) per 100,000. Meta-analyses of adjusted estimates (OR = 0.66 (0.49 to 0.89); p = 0.007; I² = 90%), unadjusted estimates (OR = 0.63 (0.51 to 0.77; I² = 74%; p = 0.000)), and a sub-group of prospective cohorts (OR = 0.67 (0.48 to 0.94; p = 0.022; I² = 16%)) had a lower risk of PS in TRA (without indication of publication bias). SSA confirmed the pooled sample size was sufficient to support these conclusions. Meta-regression decreased the unexplained heterogeneity but did not identify any independent predictor of PS nor any effect modifier.

Conclusion

Periprocedural stroke remains a rare and hard-to-predict adverse event associated with cardiac catheterization. TRA is associated with a 20% to 30% lower risk of PS in real-world/common practice settings. Future studies are unlikely to change our conclusion.

KEYWORDS:

• Stroke
• catheterization
• radial
• femoral
• incidence
• observational
• cohort
• real-world
• accession site
• meta-analysis
• meta-regression
• trial sequential analysis

Acknowledgments

We thank Janus Engstrøm (Copenhagen Trial Unit) for IT support in relation to TSA application, Thomas O. Secrest for proofreading and Verka Horackova for graphical support.

Declaration of interest

J Tužil works for and T Dolezal is the owner/director of iHETA (a non-profit research organization) and Value Outcomes (a consultancy company in the field of health economics/pharmacoeconomics, clinical trials), which collaborate with the pharmaceutical industry. J Matějka and M Mamas are interventional cardiologists, J Matějka received speaker honoraria from Servier, Novartis, and AstraZeneca. M Mamas has received unrestricted educational grants from Terumo and Abbott vascular, and speaker’s fees from Daiichi Sankyo, BMS and Terumo.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

J.M. designed the hypothesis and J.T. wrote the protocol and the draft manuscript, both reviewed literatures, extracted data, interpreted results and developed the manuscript. J.T. designed and performed the statistical analyses. M.M. and T.D. revised and interpreted the results and continuously revised the manuscript.

Data statement

All analyses can be easily reproduced using the information provided in Table 1, Table 2, and Supplementary Table 2.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/14779072.2023.2187378

Additional information

Funding

This paper was not funded.