This document discusses the advantages and disadvantages of radial versus femoral artery access for percutaneous coronary intervention (PCI). Key findings from the RIVAL trial show that while radial access was associated with fewer major vascular complications compared to femoral, there was no significant difference in rates of death, heart attack, stroke or bleeding. However, radial access was linked to shorter procedure time, less bleeding, lower costs, fewer complications and greater patient satisfaction. The document concludes that while both approaches have merits, operators should become proficient in both to choose the most appropriate access site based on the patient's clinical situation and preferences.

1. You Need To Be Proficient
with Both
Jeffrey W. Moses, MD
Columbia University Medical Center
The Cardiovascular Research Foundation

2. Disclosure Statement of Financial Interest
I, Jeffrey Moses DO NOT have a financial
interest/arrangement or affiliation with
one or more organizations that could be
perceived as a real or apparent conflict of
interest in the context of the subject of
this presentation.

3. Why Would I Convert from Femoral?
Even though
• I did hundreds of brachial
procedures with non-preformed
catheters so can easily manipulate
in the aorta from the arm
• Can start an a- line

4. RIVAL: Primary and Secondary Outcomes
Radial
(n=3507)
%
Femoral
(n=3514)
%
HR
95% CI
P
3.7
4.0
0.92
0.72-1.17
0.50
Death, MI, Stroke
3.2
3.2
0.98
0.77-1.28
0.90
Non-CABG Major
Bleeding
0.7
0.9
0.73
0.43-1.23
0.23
Primary Outcome
Death, MI, Stroke,
Non-CABG Major Bleed
Secondary Outcomes

5. Other Outcomes
Radial
(n=3507)
Femoral
(n=3514)
P
Access site Cross-over (%)
7.6
2.0
<0.0001
PCI Procedure duration (min)
35
34
0.62
Fluoroscopy time (min)
9.3
8.0
<0.0001
Persistent pain at access site >2
weeks (%)
2.6
3.1
0.22
Patient prefers assigned access
site for next procedure (%)
90
49
<0.0001
Symptomatic radial occlusion requiring medical attention 0.2% in radial group

6. Other Outcomes
Radial Femoral
(n=3507) (n=3514)
%
%
HR
95% CI
P
Major Vascular Access
Site Complications
1.4
3.7
0.37
0.27-0.52
<0.0001
- Pseudoaneurysm
needing closure
0.2
0.7
0.30
0.13-0.71
0.006
Other Definitions of Major Bleeding
TIMI Non-CABG Major
Bleeding
0.5
0.5
1.00
0.53-1.89
1.00
Blood transfusion
1.1
1.3
0.87
0.56-1.33
0.51
ACUITY Non-CABG
Major Bleeding
1.9
4.5
0.43
0.32-0.57
<0.0001
1.2
3.0
0.40
0.28-0.57
<0.0001
- Hematomas

7. Patient Satisfaction
• Among the patients who had both methods, the
transradial method was strongly preferred in 80% and
moderately preferred in 7%, with only 2% preferring
transfemoral catheterization
Number of Patients
120
100
80
P<0.0001
60
40
20
0
Strongly
Prefer
Radial
No
Preference
Cooper et al. Am Heart J 1999;138:430-436
Strongly
Prefer
Femoral

8. Now What?

9. Now What?

10. Financial Savings
• Total adjusted costs
favored TRI by $553
(p=0.033)
• Day of procedure costs
were similar TFI and TRI
• Costs from the following
day to discharge were
significantly lower with
TRI, primarily due to a
decreased LOS (20%
attributable to decrease
bleeding complications)
• Same Day PCI
P value
All cases
229
-331
571 912
222
.001
775
Low Risk
Moderate Risk
High Risk
.431
69
478 887
19
917
Femoral better
.022
1,814
Radial better
¡ Estimated savings to healthcare system = $1.8 billion annually
Safley et al. Am Heart J 2013;165:303-309
Resnic. Circulation 2007;115:2248-2250
.045

11. “Dabbling” in one or the
other is a disservice to
the patients

12. Radiation Exposure
• Procedural volume
was a more important
predictor of radiation
dose than access site
• Experience was the
most important factor
in reducing radiation
exposure from
coronary procedures
regardless of whether
radial or femoral
access was performed
Jolly et al. J Am Coll Cardiol Intv 2013;6:258-66

13. Impact of Access and
Antithrombotic Therapy in ACUITY
GP/IIbIIIa +
Hep
Bivalirudin
P Value
TF (11,989)
5.8
3.0
<0.0001
TR (798)
2.2
3.3
0.19
Hamm et al, Euro int 2009;5:115

14. DES in Trifurcation Lesion
Crush for LMT Trifurcation
Baseline angiogram

15. DES in Trifurcation Lesion
Crush for LMT Trifurcation
1st Cypher 2.25x18 mm
2nd Cypher 3.0x18 mm
3rd Cypher 3.0x 18 mm

16. • Sure you can do complex
anatomy (sheathless guides,
guidelines etc.)
• But why push it?

17. Ultra Complex Transradial Access and
Dog Walking…….
Yeah You Can do it……but…..why?

18. Angiographic Representation
of Access Anatomy
AP
Ipsilateral Oblique
Inguinal ligament
Inguinal ligament
Inferior epigastric
Inferior epigastric
Circumflex iliac
Circumflex iliac

19. Ultrasound Guided Access

20. Strategy of VCD and
Bivalirudin vs Compression
Bleeding (%)
Bleeding rates by Candidate Bleeding Avoidance Strategies for the Overall Study
Population and by Preprocedural Estimates of Bleeding Risk
P<0.001
7
6.1
6
300,000
5
4
3
2
1
0
high risk
PCI pts
4.6
P<0.001
2.8
2.1
1.6
P<0.001
P<0.001
0.9
M C B D
Overall
0.9 0.9
2.3
1.9
3.8
2.3
1.4
0.6 0.4
0.8
M C B D
M C B D
M C B D
Low (<1%) Intermediate (1-3%) High (>3%)
ACC NCDR
Marso et al JAMA 2010; 303:2156-2164
62%

21. Why Femoral?
• More versatile
• Less flouro/contrast
• Larger guides
• Post op anatomy
• “Super” back-up needed
(e.g., CTO, calcium)
• Need proficiency for other
procedures (TAVC, PVAD etc.)

22. Why Radial?
• Patient preference
• Fewer access issues
• Lab throughput easier
• Cheaper
• Enhances ambulatory program
Who cares if it reduces MACE or not?

23. • Compared with the radial approach, the
femoral approach
¡Has less cross-over
¡An easier learning curve
¡Probably less radiation
• But, the data also shows us that the
femoral approach is associated with
¡Higher bleeding and vascular
complications, particularly in STEMI
patients
¡Higher costs
¡Lower patient satisfaction

24. When Radial
• “Default” in diagnostics
• Do not anticipate complex
anatomy
• PVD
• Obesity

25. When Femoral
• Severe CKD (for IVUS guided
ultralow contrast PCI)
• CTO
• Vein grafts
• Large guides needed
• Patient preference

26. How Do I Decide ?
Complexity
Simplicity
of
access
Femoral
Radial