This document discusses trends in vascular access sites for coronary procedures. It notes that radial access has significantly increased over time in many countries, now accounting for over 75% of procedures in some registries. Some benefits of radial access include lower mortality, major adverse cardiac and cerebrovascular events, major bleeding, and vascular complications compared to femoral access. However, it also notes there is a paradoxical increase in vascular complications with femoral access as radial access has become more prevalent. This may be due to adverse patient characteristics now associated more with femoral procedures. Overall, while radial access appears beneficial, patient factors remain an important determinant of outcomes. Operator experience with femoral access is still important.

1. Is femoral proficiency lost
when radial access thrives?
Stanislaw Bartus
Jagiellonian University
András Komócsi
University of Pécs, Hungary

2. Disclosure
I have no conflict of interest to declare

3. Coronarography
vasular access in 2015 vs diagnosis (in comparison to 2014)
32%
68%
femoral radial
23%
77%
femoral radial
24%
76%
femoral radial
20%
80%
femoral radial
STEMI
↑8%
NSTEMI
↑7%
UA
↑10%
SCAD
↑6%
National registry of interventional
cardiology procedures

4. Coronarography
radial access 2009 - 2015
National registry of interventional
cardiology procedures
24%
30%
36%
47%
59%
66%
77%
0%
20%
40%
60%
80%
100%
2009 2010 2011 2012 2013 2014 2015

5. ACCESS SITE PRACTICE
EVOLUTION IN THE UK
Jim Nolan, TCT 2015

6. When I don’t want to use radial
access ….
• Patient on dialysis
• Anticoagulation (?)
• Obesity, cachexia, low body weight, female gender, Raynaud ph,
• Patient preference
• Not possible to pass through radial/brachial/subclavian aa.
• Patient in shock, no radial pulse
• CTO, LMCA, complex procedures w/severe calcification
• Impaired Procedural success and applicability
• Learning curve
Personal experience 1996-2016

7. The Benefits Conferred by Radial Access for Cardiac Catheterization Are Offset
by a Paradoxical Increase in the Rate of Vascular Access Site Complications With Femoral
Access
The Campeau Radial Paradox
Azzalini L. J Am Coll Cardiol Intv 2015;8:1854–64

8. The Benefits Conferred by Radial Access for Cardiac Catheterization Are Offset
by a Paradoxical Increase in the Rate of Vascular Access Site Complications With Femoral
Access
The Campeau Radial Paradox
Azzalini L. J Am Coll Cardiol Intv 2015;8:1854–64

12. Influence of Arterial Access Site Selection on Outcomes in
Primary Percutaneous Coronary Intervention
Are the Results of Randomized Trials Achievable in Clinical Practice?
Mamas M, JACC CardiovascInterv. 2013; 6: 698-706
The influence of access site
selection was studied in 46,128
PPCI patients;
TFA was used in 28,091 patients
and TRA in 18,037.
This analysis of a large number of
PPCI procedures demonstrates that
utilization of TRA is independently
associated with major reductions in
mortality, MACCE, major bleeding,
and vascular complication rates.

13. A. Komocsi et al.:Mortality after transradial approach in ST-segment elevation myocardial infarction.
Do we see the forest for the trees? Int J Cardiol. 2013 Oct 3;168(3):3050-3

14. 21,321 HUMIR entries
from March 1, 2013, to March 1, 2015
17,892 angiography cases
ScreeningEligibilityIncluded
3429 patients non-invasive
treatment
Exclusion 7467 patients
due to missing data
10,485 Unmatched population
9631
transradial
808
transfemoral
1278 Matched population
639
transradial
639
Transfemoral
Propensity score calculation
and matching
Propensityscore
matched
7.7%

15. Clinical characteristics Entire cohort Propensity matched cohorts
Transradial
(n=9631)
Transfemoral
(n=808)
P value Transradial
(n=639)
Transfemoral
(n=639)
P value
Age, years* 63.4 ± 12.3 67.3 ± 12.2 <0.001 66.9 ± 12.4 66.3 ± 12.3 0.331
Male 62.5 56.7 <0.001 57.7 57.0 0.821
Medical history
Hypertension* 76.8 77.0 0.928 73.7 76.4 0.301
Diabetes 30.0 30.3 0.875 29.0 29.4 0.902
- insulin 11.1 15.0 0.003 12.1 13.5 0.532
Hyperlipidaemia* 37.3 37.5 0.939 37.6 38.2 0.863
Smoking *
(current/past/never)
26.7/9.9/63.5 18.9/6.7/74.4 <0.001 21.0/9.2/69.8 22.2/8.3/70.4 0.447
History of heart failure 9.4 17.7 <0.001 11.7 13.6 0.355
History of myocardial
infarction
20.5 30.4 <0.001 25.2 26.3 0.701
History of stroke* 7.8 10.5 0.006 8.3 9.7 0.434
History of PCI 18.5 25.1 <0.001 22.8 21.6 0.638
History of CABG 4.1 16.6 <0.001 7.8 8.6 0.684
Peripheral artery
disease*
12.0 14.5 0.036 13.0 13.6 0.805
STEMI* 50.6 62.3 <0.001 62.1 61.0 0.730
Killip state (I, II. III, IV) 83.6/12.2/2.2/2
.1
85.4/9.9/3.0/1.
6
0.437
Heart rate* 79.9 ± 17.3 82.0 ± 19.5 0.003 81.6 ± 18.7 81.6 ± 18.7 0.974
Systolic blood pressure* 135.4 ± 24.0 127.7 ± 30.0 <0.001 130.7 ± 24.6 131.8 ± 28.0 0.467
Diastolic blood pressure 80.1 ± 16.3 76.3 ± 19.1 <0.001 78.4 ± 14.4 78.6 ± 15.7 0.796
Weight (kg) 80.2 ± 16.3 79.0 ± 16.2 0.061 79.2 ± 17.0 78.0 ± 15.8 0.284

16. Follow-up (days)
Cumulativesurvival PS matched cohort (n=1278)
Log rank p < 0.05Log rank p < 0.001
STEMI
(n=787)
NSTEMI
(n=491)
Log rank p < 0.05 Log rank p = 0.07
P-value Hazard Ratio (HR)
95.0% CI for HR
Lower Upper
PS matched TRPCI 0.000 0.605 0.479 0.763
cohort TRAFO 0.000 1.766 1.336 2.332
Propensity score 0.000 181.363 58.724 560.123
NSTEMI TRPCI 0.023 0.631 0.424 0.939
TRAFO 0.000 2.234 1.458 3.423
Propensity score 0.004 21.043 2.634 168.119
STEMI TRPCI 0.001 0.602 0.452 0.803
TRAFO 0.012 1.615 1.109 2.350
Propensity score 0.000 466.801 123.976 1757.629

17. THERE IS NO PARADOX ?
• According to large metaanalyses, of randomized and observational
studies confirm the benefit of TR approach. However observed
complication rates are influenced and related to the documented
adverse patient and procedural characteristics
• In the current era of high TR and selective TF access, the patient
caracteristics have more important impact on survival than the access
itself of that of the transfusion
• But, be carefull: in some centers it can be observed…so train your staff
in transfemoral access !!!!
Lengyel magyar jó barát,
együtt harcol, s issza borát !
Polak, Węgier, dwa bratanki, i do szabli, i do szklanki