Durham, NC - Using the radial artery for access to the heart during percutaneous coronary intervention (PCI) is extremely rare in clinical practice, but despite its limited use, the approach is associated with equivalent procedural success to femoral access as well as lower rates of bleeding and vascular complications, even among high-risk patients, a new study has shown [1].

"Studies have shown that up to 85% of bleeding complications in patients undergoing PCI are related to the access site, and we know that bleeding in and of itself is associated with an increased risk of mortality and morbidity," lead investigator Dr Sunil Rao (Duke Clinical Research Institute, Durham, NC) told heartwire. "If you take the access site out of the equation, we have the potential to substantially reduce bleeding complications, which is what the clinical trials of radial vs femoral have shown in the past."

People who do a lot of radial PCI actually look for an excuse not to do it.

Publishing their real-world results in the August 2008 issue of the Journal of the American College of Cardiology: Cardiovascular Interventions, the investigators analyzed data from the National Cardiovascular Data Registry, selecting first-time PCIs performed with radial or femoral access in nonemergency cases. The purpose of the analysis was to determine how often radial PCI was performed in the US, especially in those at high risk for bleeding complications, and assess the outcomes of the procedure in the clinical setting.

They identified 593 094 patients who underwent PCI between January 2004 and March 2007. Of those, 1.32% were treated using radial-artery access. Despite the limited use of radial PCI during the period, the approach was associated with a similar rate of success and a 58% lower risk of bleeding complications. The reduction in bleeding was even more pronounced among women, the elderly, and patients undergoing PCI for acute coronary syndrome.

"The traditional approach has been to say, 'Here is a patient that would be good for the radial approach,' " said Rao. "People who do a lot of radial PCI actually look for an excuse not to do it. The radial route should be the default approach now, with the availability of equipment and now the data showing that you don't sacrifice anything when you do the radial approach."

While there is a tremendous focus on reducing bleeding complications in modern-era PCI, Rao said most efforts are directed toward pharmacologic strategies, but simply switching to radial-access PCI would be a way to reduce those risks. The MORTAL study, he noted, even showed a mortality benefit with the radial approach over femoral access at one year, a benefit likely driven by the reduction in bleeding.

While there is a learning curve, it's really not that much harder. It's one of those situations where if you do a few of them, you really get the hang of it.

Asked about some of the difficulties in getting clinicians to adopt the radial approach, Rao said there might be some preconceived notions about the difficulty of the approach or physician inertia to change, especially among practicing cardiologists who like doing things a certain way or who haven't been exposed to the technique during training. He added that there hasn't been a concerted effort from industry to push the radial approach, although he suspects all of these barriers will be overcome, especially with the increased attention to bleeding risks in PCI.

"The learning curve with the radial approach is variable, and it depends on how tactile clinicians are with catheter manipulation," said Rao. "I can tell you that while there is a learning curve, it's really not that much harder. It's one of those situations where if you do a few of them, you really get the hang of it. We've encouraged our fellows to learn it during training, so that when they get out, they'll already have the techniques in the back of their mind."