Radial access first for PCI in acute coronary syndrome
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Jeffrey A. Marbach1 · Saad Alhassani1 · George Wells2 · Michel Le May1 1
CAPITAL Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada 2 Division of Statistics and Epidemiology, University of Ottawa Heart Institute, Ottawa, Canada
Radial access first for PCI in acute coronary syndrome Are we propping up a straw man? In patients presenting with an acute coronary syndrome (ACS), coronary angiography and subsequent percutaneous coronary intervention (PCI) represent the recommended revascularization strategy [1–3]. This strategy has been shown to improve clinical outcomes, including survival. However, periprocedural bleeding, a well-recognized complication of angiography and PCI, is associated with increased costs, prolonged hospital stays, and is an independent predictor of short-term and long-term mortality [4–7]. Of concern is that up to 50% of periprocedural bleeding events are due to access site complications [7]. Hence, several approaches have been evaluated over the past two decades to reduce periprocedural bleeding and access site complications; these include decreased use of glycoprotein IIb/IIIa inhibitors (GPIs), replacement of unfractionated heparin (UFH) with newer antithrombotic agents for procedural anticoagulation, use of vascular closure devices, and preferential use of the radial artery over the femoral artery for vascular access [8–13]. While all of these bleeding-reduction strategies have demonstrated efficacy to some extent, the discussion over radial access (RA) versus femoral access (FA) has been among the most controversial. Percutaneous RA forcoronaryangiography and PCI was first described by Lucien Campeau in 1989, prior to which FA was the primary approach used in clinical practice [14]. This initial 100-patient case series, which reported no clinically significant complications, presented RA
as an appealing alternative to FA, which has been associated with a 2–6% rate of vascular access site complications [15]. In the three decades following Campeau’s publication, the difference in outcomes between RA and FA have been compared in tens of thousands of patients. During this time, RA has steadily gained in popularity among interventional cardiologists thanks to evidence demonstrating a reduction in bleeding events and access site complications [16]. European and Canadian practice guidelines have followed this trend and currently recommend RA as the default strategy for non-ST-elevation and ST-elevation ACS; however, U.S. guidelines have yet to provide a recommendation [2, 17, 18]. Nevertheless, there remains ongoing debate as to the validity of a default RA approach due to diverging conclusions from several of the large randomized trials, which have enrolled patients with varying presentations—ranging from unstable angina to non-ST-segment elevation myocardial infarction (NSTEMI), to ST-segment elevation myocardial infarction (STEMI)—undergoing PCI at varying degrees of urgency, and employing numerous different anticoagulation and antipla
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