Access vs non-access site bleeding and risk of subsequent mortality and MACE This study aimed to analyze the incidence and prognostic impact of access site versus non-access site bleeding in patients undergoing percutaneous coronary intervention (PCI). The meta-analysis included 38 studies and over 520,000 patients. It found that access site bleeding occurred in 11.2% of patients while non-access site bleeding occurred in 10.2% of patients. However, non-access site bleeding was associated with a higher crude mortality rate of 8.3% compared to 2.8% for access site bleeding. Further analyses confirmed that non-access site bleeding carried a greater risk of subsequent mortality and major adverse cardiac events than access site bleeding. The

1. Access vs non-access site bleeding and
risk of subsequent mortality and MACE
Mamas Mamas
Professor of Cardiology
Keele University

3. • Previous literature reported conflicting data about both the
incidence of access and non–access site-related bleeding
complications and their relative prognostic impacts
• Both incidence and prognostic impact will be determined by
definition of major bleeding, severity of bleeding event, cohort
studied, pharmacology used and way the bleed treated.
• No previous systematic review or meta-analysis published
studying the prevalence or prognostic impact of site-specific
bleeding complications after PCI.
Background

4. Incidence: Depends on definition
Bleeding definitions composed of:
• Clinical events: intracranial haemorrhagic, retroperitoneal
bleed, haematomas etc
• Change in laboratory parameters such as differing values of
Hb drops, HCT changes
• A clinical outcome such as death, receipt of blood transfusion
Different definitions are composed of different
combinations of above

6. Meta-analysis of 38
relevant studies
including 520,401
patients
3.3 fold independent
increased risk of
mortality following
major bleed

7. Prognostic impact depends on definition

8. Aim
• The aim of the study is to provide an overview
of site specific bleeding events and study their
prognostic impact on mortality and MACE

9. Methods
• Studies selected that investigated the impact of site-specific
bleeding on mortality or MACE in patients who underwent
PCI
• A search of Embase (1974-March 2014) and Medline (1946-
March 2014) on Ovid using search terms:

10. Study flow diagram
2,400,645 subjects with 106,490 bleeding events (4.5%)

11. Studies included

12. Access vs non-access site bleeding
• 7 studies evaluated outcomes with access-site related bleeding
complications (33,677 bleeding events in 301,404 patients;
prevalence 11.2%)
• 6 studies evaluated non-access site bleeding (29,600 bleeding
events in 290,456 patients; prevalence 10.2%)
• Crude mortality rates:
– Access site bleeding: (2.8%)
– Non-access site bleeding: (8.3%)
– Patients without bleeding complications (1.9%)

13. Risk of mortality in access vs non-access
bleeding complications

14. Sensitivity analyses
• Similar findings in sensitivity analyses:
– RCTs only
– Studies that adjusted for anti-coagulant use
– Studies that adjusted for ACS vs non ACS

15. Mechanism: Related to severity of bleed ?
• Analysis of 3,694 patients who sustained bleeding event
(4900 bleeding events) in SYNERGY Trial (9978pts)
Vavalle et al. JACC Intv 2013

16. Mechanism? : Treatment of bleed

18. Impact of site-specific bleeds

19. Conclusions
• Access site related bleeding complications have a similar
incidence to those derived from non-access site sources
• The prognostic impact of major bleeding complications
depend on anatomical source
• Both access and non-access site bleeding complications
associated with adverse outcomes
• Non-access site have a greater prognostic impact
• Bleeding avoidance strategies such as access site choice and
pharmacology should be considered as important parts of the
PCI procedure.