Radialists perform better femoral PCI according to a study. While radial access has benefits, not all hospitals and operators have adopted it due to challenges like a learning curve. Studies show that default radial operators in a radial center who occasionally need to use femoral access have lower rates of access site complications and mortality compared to femoral operators. Analysis of large datasets from the UK also indicate reduced access site complications and mortality with radial access compared to femoral for PCI.

1. RADIALISTS PERFORM BETTER
FEMORAL PCI
Jim Nolan
University Hospital of North Staffordshire

2. WHY DOESN’T EVERYBODY USE
RADIAL ACCESS
• Learning curve
• Extended Procedural duration
• Increased nursing input
• Patient preference
• Impaired Procedural success and applicability
• Increased cost of radial specific kit
• Radiation exposure
• If they do they will lose the ability to do safe TFA

3. RADIAL ENVIRONMENT
• Small calibre vessel
• Spasm risk
• Anatomical variation
• Advanced guide catheter techniques
• Skilled high volume TRA operators are
highly proficient interventionists ( as are
their teams )

4. FEMORAL ENVIRONMENT

5. FACTORS THAT MAY ACT TO INCREASE TFA
COMPLICATIONS IN RADIAL CENTERS
• Fewer TFA procedures
• Reduced exposure to technique for
operators in training and daily practice
• Reduced institutional experience with post
TFA care

6. ACCESS SITE PRACTICE EVOLUTION
IN THE UK

7. FACTORS THAT MAY ACT TO REDUCE TFA
COMPLICATIONS IN A RADIAL CENTER
•When a TRA operator has to perform a TFA
case it is done with maximum attention to
puncture, haemostasis and aftercare
•TRA operators performing TFA frequently
use guidance for the puncture
•Limited use of VCDs

8. VACD – DEVICE FAILURE RATE
(Sesana et-al, JIC 2000, n = 827)
9
11
0
2
4
6
8
10
12
COLLAGEN PLUG SUTURE
FAILURERATE(%)

9. VCD META ANALYSIS – RANDOMISED +
OBSERVATIONAL
(Nikolsky et-al, JACC 2004, n = 37,066)

10. COMPLICATIONS IN VCD MA
(Biancari et-al, Am Heart J 2010, n=7528)

11. HOW CAN WE INVESTIGATE THE
SAFETY OF TFA IN RADIAL
CENTERS

12. PATIENTS UNDERGOING PCI FROM
THE FEMORAL ROUTE BY DEFAULT
RADIAL OPERATORS
Ihsan M. Rafie, MD; Muez M. Uddin, MD; Nicholas Ossei-Gerning, MD; Richard A. Anderson, MD; Timothy D.
Kinnaird*, MD
Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom
Eurointervention 2014

13. CARDIFF STUDY
• 1352 PCI procedures performed by default
radial operators over 12 month period
• TFA used when operator felt it to be
technically and clinically appropriate ( skilled
TFA operators)
• ACUITY based definition of TFA related
complications ( included haematomas that
were not associated with Hb fall and required
no intervention)
• TFA utilised in 351 (25.2%) cases

14. WHAT TYPE OF PATIENT HAD TFA IN
THE CARDIFF STUDY
• Female gender (41% v 21%)
• Older (65 v 63)
• Lower BMI (80% v 84%)
• Shorter stature (167 v 171)
p < 0.001 for all comparisons

15. WHAT TYPE OF PROCEDURE WAS DONE
VIA TFA IN THE CARDIFF STUDY?

16. RESULTS IN TFA CASES
• 44 patients (12.5%) had femoral vascular
complication (ACUITY definition)
• 22 of these ( 6.25%) were haematomas with
no intervention required
• 22 (6,25%) had TFA complication that required
some form of intervention

17. The use of radial access decreases the risk of
vascular access-site-related complications at a
patient level but is associated with an
increased risk at a population level: the radial
paradox
Lorenzo Azzalini, MD, MSc; E. Marc Jolicoeur*, MD, MSc, MHS
Interventional Cardiology Division, Dept. of Medicine, Montreal Heart
Institute, Université de Montréal, Montréal, QC, Canada

18. INFLUENCE OF RADIAL ACCESS ON BLEEDING
AND VASCULAR COMPLICATIONS – META
ANALYSIS OF RANDOMISED TRIALS
(Jolly et-al,lancet,2011, n=10,000+)

19. META-ANALYSIS OF RCT COPARING RADIAL v FEMORAL
ACCESS IN STEMI PATIENTS UPDATED TO INCLUDE RIFLE
(Mamas et-al,Heart 2011,n=3978)
OR for mortality = 0.53 (95% CI 0.38-75); P<0.001 for radial

20. BRITISH CARDIOVASCULAR
INTERVENTION SOCIETY
• BCIS established in 1998 to promote and
monitor PCI activity in UK
• Collects data on all PCI performed in UK via
central electronic database ( 113 patient
,procedural and outcome variables )
• Robust mortality data using NHS number
• Linked to NHS central register
• Legal requirement for every death in UK to be
recorded

21. PCI OUTCOMES ACCORDING TO CLINICAL
SYNDROME AND ACCESS SITE
(n=433,000 JACCI 2014)
0.1 1
Favours TRA Favours TFA
Access site complication
0.20 (0.13-0.29) p<0.001
Bleed
0.53 (0.43-0.66) p<0.001
MACE
0.71 (0.65-0.78) p<0.001
30-Day Mortality
0.69 (0.62-0.77)
EMERGENCY
Access site complication
0.24 (0.19-0.30 p<0.001
Bleed
0.40 (0.31-0.52) p<0.001
MACE
0.85 (0.77-0.94) p<0.001
30-Day Mortality
0.85 (0.76-0.96) p=0.01
URGENT
Access site complication
0.22 (0.17-0.29) p<0.001
Bleed
0.24 (0.15-0.39) p<0.001
MACE
1.04 (0.92-1.18) p=0.53
30-Day Mortality
0.78 (0.57-1.03) p=0.77
STABLE
Figure 3. Forest plot of log odds ratio of outcomes following
multivariate logistic regression
Variables included in analysis: Age, sex, prior MI, prior CABG, prior PCI, diabetes,
hyperlidaemia, hypertension, peripheral vascular disease, previous stroke, smoking, pre-
procedural ventilation, use of circulatory support and pre-procedural shock.

22. UK BCIS PPCI
N=46,128
PPCI
39% TRA
TRA for PPCI
increased from
12% to 49%
Mamas M, JACC Cardiovasc Interv. 2013; 6: 698-706
TRM 2013

23. ACCES SITE RELATED OUTCOMES IN
CARDIOGENIC SHOCK
(AHJ,2014, n=7,231)

24. WHO STILL DOES TFA IN UK ?

25. GEOGRAPHICAL DISTRIBUTION OF
TRA IN UK

26. WHAT TYPE OF OPERATORS DO TFA IN UK?
Kinnaird T et al, O Heart 2014

27. CLOPIDOGREL USE IN STEMI PCI

28. UK FEMORAL OPERATORS
• Old guys based in south
• Low volume operators
• Slow to modify practice

29. EVALUATION OF TFA ACCESS SITE
PRACTICE IN MAJORITY RADIAL
CENTERS
• Years 2006 to 2010
• Single access site recorded
• TRA or TFA

30. P=0.007
P=0.26
P=0.6

31. ARE RADIAL CENTERS BETTER AT EVERYTHING?

32. WHAT DOES BCIS TELL US
• TRA benefits seen in RCT translate into
clinical practice
• Radial centers do better radial PCI
• No increase in TFA complications in radial
centers
• TFA procedures performed in a TRA center
were associated with an observed
reduction in mortality at 30 days
• In MVA OR 0.86, 95% CI 0.76-0.99,
p=0.032

33. Limitations
• Observational data
• Unmeasured confounders
• Data collected in an evolutionary period (operators
have TFA background)
• May not apply to TFA cases in very high volume TRA
centers ( case mix effects )

34. CONCLUSIONS
• Radial centres do better femoral PCI
• Radial centres do better radial PCI
• Radial centres do better PCI