Transradial access versus transfemoral access: a comparison of outcomes and efficacy in reducing hemorrhagic events

ABSTRACT

Introduction: The radial artery is currently the most widely used access site for PCI procedures both acute and stable patient settings. Thanks to advantages in pharmacological therapy as well as in interventional devices, the rate of ischemic complications following PCI has significantly decreased. Nevertheless, this has been counterbalanced by an increased risk of periprocedural and late bleeding event, that can occur both at access and non-access sites. Choice of access site for PCI is of paramount importance to reduce the risk of access-related bleeding events.

Areas covered: The aim of this review is to provide an overview of the actual available evidence comparing the transradial versus transfemoral approach to reduce hemorrhagic events.

The most robust evidence comes from large randomized trials, partly also from observational registries, which compared the transradial and transfemoral approach.

Expert opinion: Results show that radial access has proved to be decisive in reducing the incidence of hemorrhagic events. Furthermore, it showed a significant reduction in mortality and AKI compared to transfemoral access. However, increased experience in the use of the radial approach has led to less practice in the use of the femoral approach, which may be useful in cases of emergency, complications or inability to use the radial artery.

KEYWORDS:

• Bleeding
• femoral
• radial
• Radial artery access
• vascular access
• percutaneous coronary intervention
• acute coronary syndrome

Article highlights

• Percutaneous coronary intervention (PCI) represents the most common form of revascularization in patients with coronary artery disease, both in the acute and in stable setting. The new antiplatelet and antianticoagulant strategies protect against ischemic events but increase the risk of bleeding events. Major bleedings are correlated with both short- and long-term adverse outcomes, including death, MI and cerebrovascular accidents.

• The use of transradial rather than the transfemoral approach for PCI, has a significant impact in reducing the bleeding complications and consequent worse outcomes. Most complications concerning femoral access are related to haemorrhagic events, these have been shown to be an independent predictor of 1-year mortality.

• The RIVAL trial and the MATRIX trial are the two largest studies that compared radial and femoral access in the PCI. While in the RIVAL trial the results on bleeding in favour of radial access were not evident, in the MATRIX trial the radial approach has been shown to reduce major bleeding, especially related to the access site, and NACE.

• VCDs have been proposed to bridge the gap, in terms of vascular complications, between radial and femoral access. Current scientific evidence shows that the planned objective is not supported by the results.

• Radial access has been shown to be superior in preventing AKI, particularly by decreasing the incidence of major bleeding, volume depletion and transfusions.

• Routine use of radial access has contributed to create the ‘Campeau Paradox’ with a loss of experience among operators with femoral access and increased femoral access site complications.

Declaration of interest

The authors have no 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

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

Additional information

Funding

This paper was not funded.