Radialists perform better femoral PCI - Mamas Mamas

1. Changes in access site practice in the UK.
Have femoral outcomes been compromised
by the switch to radial?
Mamas Mamas
Professor of Cardiology
Keele Cardiovascular Research Group
Keele University, UK
#RadialFirst

2. Disclosures
• None
#RadialFirst

3. Background
• Radial artery has become the default access site in choice for
PCI in many countries
• Several RCTs have shown reduced risk of mortality associated
with radial access in high risk populations
• National registry data from many countries has shown
decreased mortality risk associated with transradial access.
• ESC has given transradial access class 1A indication for ACS
PCI
#RadialFirst

4. Radial Growth in UK
#RadialFirst

5. Radial 2005
Mamas et al. Circulation. 2016;133(17):1655-67.#RadialFirst

6. Radial 2006
Mamas et al. Circulation. 2016;133(17):1655-67.#RadialFirst

7. Radial 2007
Mamas et al. Circulation. 2016;133(17):1655-67.#RadialFirst

8. Radial 2008
Mamas et al. Circulation. 2016;133(17):1655-67.#RadialFirst

9. Radial 2009
Mamas et al. Circulation. 2016;133(17):1655-67.#RadialFirst

10. Radial 2010
Mamas et al. Circulation. 2016;133(17):1655-67.#RadialFirst

11. Radial 2011
Mamas et al. Circulation. 2016;133(17):1655-67.#RadialFirst

12. Radial 2012
Mamas et al. Circulation. 2016;133(17):1655-67.#RadialFirst

13. Estimated 450 lives “saved” by change in practice
Estimated 264 lives “lost” by failure to adopt practice across the board

14. Actual savings (millions) vs possible savings
if TRA uptake rates matched region with
the highest uptake (North East)

15. Background
• Even in high volume TRA centres, situations where
PCI needs to be undertaken in TFA between 5-10% of
cases
• Concerns that transition to TRA may compromise
TFA related outcomes, particularly given that femoral
access would be used in higher risk cases.
#RadialFirst

16. • Comparison of Access site complications in 12,396 femoral procedures
compared between 1996-1998 and 2006-2008

17. Clinical and procedural characteristics

18. Incident vascular complications
Results

19. Aim
• To determine whether a change in access site practice towards
TRA at a centre level over time has led to worse TFA
outcomes
• To determine whether improved clinical outcomes achieved by
the national adoption of radial access are attenuated by a loss
of femoral proficiency
Circ Cardiovasc Intv 2017

20. Methods
23/92 centres
16/92 centres
53/92 centres
2006 YEAR 2013
LowTFAProportionHigh
High FP centres > 66.7%
low FP centres < 33.6 %
Intermediate FP centres 33.6-66.6%

21. Methods
• Design Retrospective observational cohort study
• Data UK BCIS PCI registry
• Time period 2006 to 2013 (7 years)
• Cohort all femoral-only procedures in England and Wales
• Outcome 30-day mortality, vascular complications
• Exposure femoral experience - defined as the proportion of
femoral procedures performed by centre in 2013
• Confounders demographic, clinical, procedural factors and total
procedural volume
• Statistical modelling multiple logistic regression with
imputation for missing data

22. Differences in Practice at centre level
(92 centres, 230,755 femoral procedures)

23. Centres that remained femoral were
typically low volume
92 centres
230,755 femoral procedures

24. Demographics

26. Unadjusted 30d mortality by FP groups

27. • Demographic sex, age
• Clinical indication (elective, UA/nSTEMI , STEMI),
cardiogenic shock, respiratory support, circulatory
support, previous MI, previous CABG, hypertension,
hypercholesterolaemia, DM, renal function, smoking,
LVEF, Hx of CVA, valvular heart disease, PVD
• Procedural stent type (DES/ BMS), multi-vessel
PCI, LMS PCI, GP IIb/IIIa inhibitor use, VCD, anti-
platelet strategies
• Institutional total procedural volume in previous 12
months
Adjustment: Confounders

28. Adjusted 30d mortality by FP groups

29. Top 10 vs bottom 10 FP centres
Top 10 Radial centres in 2013; TRA proportion between 87.1 - 94.8%
Top 10 femoral centres in 2013; TFA proportion between 77.8 - 98.4%

30. “Non-Complex” Procedures (CS, circulatory
support and ventilation excluded)

31. Vascular Complications

32. Sensitivity analysis: stratification by FP in
the 12 mths preceding procedure date
PCI
Time
Femoral proportion in preceding 12 mths

33. Risk adjusted femoral outcomes by FP

34. Conclusion
• Poorer femoral outcomes for predominantly high radial centers
are driven by the tendency of these centers to utilize femoral
access in the highest risk patients.
• Once differences in case mix are adjusted for, femoral
outcomes are similar between high and low radial proportion
centers.
• No evidence to suggest worse femoral outcomes in a country
that has transition to predominantly radial (80% of PCI radial)
at centre level
• TRA should be default access site as per current evidence basis
/ international guidelines

35. If the efficacy of TRA could be achieved by
prescribing a pill, would physicians still be
having discussions around access site ?