The impact of gender, syndrome and vascular access site on clinical outcomes following percutaneous coronary intervention

1. The impact of gender, syndrome and
vascular access site on clinical outcomes
following percutaneous coronary
intervention
Chun Shing Kwok1, Evangelos Kontopantelis1, Karim Ratib3, Azfar
Zaman2, Peter F Ludman4, Mark A. de Belder5, James Nolan3, Mamas A.
Mamas1 on behalf of the British Cardiovascular Intervention Society and
the National Institute for Cardiovascular Outcomes Research
University of Manchester1, Newcastle University2, University Hospital
North Staffordshire3, The James Cook University Hospital4, Queen
Elizabeth Hospital5
Presented by:
Dr. Chun Shing Kwok, Academic Clinical Fellow in Cardiology
Cardiovascular Institute, University of Manchester

2. Disclosures
Dr. Chun Shing Kwok and his co-authors have no relevant
financial conflicts of interest to declare.
Dr. Chun Shing Kwok is grateful to Biosensors for sponsoring his
travel expenses to present this work.

3. Introduction
SAFE-PCI: Risk of bleeding or vascular complications
among subgroups of women
Bleeding risk with femoral PCI
Doyle BJ, JACC Interv 2008
Odds ratio (95% CI)
Mamas MA, Rao SV, JACC J AInCteCrv I n2t0e1rv4 2013
Kwok CS, Open Heart 2014

4. Summary
• ↑ risk of mortality
following major bleed
after PCI
• ↓ risk of mortality with
radial access and in UK ↑
adoption radial access
• ↑ risk of bleeding among
women after femoral PCI
Aim: The aim of this study is to
1. define gender differences in access site practice in an unselected
national cohort of patients undergoing PCI.
2. study associations between access site choice and clinical outcomes
across both genders.
• Women randomized to radial
vs femoral showed no
difference in bleeding/vascular
complications

5. Methods
• Design: Retrospective cohort study of all patients who received PCI
in the United Kingdom over 6 years (Jan 2007 to Dec 2012).
• Statistical methods: We graphically examined the percentage of
radial access usage in men and women over time. Next, we present
the descriptive statistics for men and women stratified by access site.
We used multivariate logistic regressions to identify predictors of 30-
day mortality, in-hospital MACE and bleeding with consideration of
access site, gender and indication.
• Definition of endpoints:
– 30-day mortality: all cause mortality at 30 days
– MACE: composite of in-hospital mortality, in-hospital MI or re-infarction
and target vessel revascularization
– Bleeding: GI bleed, intracerebral bleed, retroperitoneal hematoma,
blood or platelet transfusion or an arterial access site complication
requiring surgery

6. Participant flow diagram

7. Adoption of radial access over time

8. Participant characteristics
Men Women
Access site Femoral access
(n=166,342)
Radial access
(n=139,055)
p-value*
Femoral access
(n=63,269)
Radial access
(n=43,456)
p-value*
Age(±SD) 63.8(±11.5) 63.1(±11.5) <0.001 68.6 (±11.6) 67.9(±11.5) <0.001
Diabetes 29,686/156,601
(19.0%)
23,824/135,166
(17.6%)
<0.001 12,168/59,811
(20.3%)
8,661/42,305 (20.5%) 0.62
Hypertension 81,210/159,986
(50.8%)
70,374/136,434
(51.6%)
<0.001 35,491/61,001
(58.2%)
25,476/42,638 (59.8%) <0.001
High cholesterol 89,399/159,986
(55.9%)
76,406/136,434
(56.0%)
0.50 34,309/61,001
(56.2%)
24,899/42,638 (58.4%) <0.001
Smoking (Ex-smoker
or current)
97,722/142,298
(68.7%)
87,205/126,840
(68.8%)
0.67 28,128/54,001
(52.1%)
22,006/39,633 (55.5%) <0.001
Previous myocardial
infarction
45,835/142,314
(32.2%)
33,723/129,673
(26.0%)
<0.001 14,451/54,574
(26.5%)
8,776/40,606 (21.6%) <0.001
Indication for PCI
Stable angina
NSTEMI
STEMI
72,182 (44.5%)
57,320 (35.3%)
32,880 (20.3%)
52,500 (38.0%)
54,074 (39.1%)
31,688 (22.9%)
<0.001
25,963 (42.0%)
23,765 (38.4%)
12,099 (19.6%)
15,593 (36.1%)
18.338 (42.4%)
9.307 (21.5%)
<0.001
Glycoprotein
inhibitor use
33,962/139,917
(24.3%)
32,051/127,154
(25.2%)
<0.001 10,852/53,262
(20.4%)
8,578/39,587 (21.7%) <0.001
Death at 30 days 2,906/166,342
(1.8%)
1,441/139,055
(1.0%)
<0.001 1,564/63,269
(2.5%)
654/43,456 (1.5%) <0.001
MACE 2,840/166,342
(1.7%)
1,626/139,055
(1.2%)
<0.001 1,502/63,269
(2.4%)
644/43,456 (1.5%) <0.001
Bleed 518/162,670 (0.3%) 226/134,603 (0.2%) <0.001 550/61,712 (0.9%) 100/41,978 (0.2%) <0.001
*p-values for continuous variables were calculated from two-sided Fisher's Exact Test and p-values for categorical variables were
calculated from one-way analysis of variance

9. Odds of adverse outcomes by radial
access
Men only Women only
*Adjusted for age, diabetes, hypertension, hypercholesterolemia, peripheral
vascular disease, previous stroke, previous MI, smoking, previous PCI,
previous CABG, indication, pre-procedure shock, pre-procedure ventilation,
circulatory support, and glycoprotein inhibitor use.

10. Odds of adverse outcomes by
radial access stratified by gender and
indication Men only Women only
*Adjusted for age, diabetes, hypertension, hypercholesterolemia, peripheral
vascular disease, previous stroke, previous MI, smoking, previous PCI,
previous CABG, indication, pre-procedure shock, pre-procedure ventilation,
circulatory support, and glycoprotein inhibitor use.

11. Adverse outcomes by radial access
stratified by gender and indication with
propensity score matching
Men only Women only

12. Discussion and Conclusions
• Radial access has grown to be the preferred access site choice across all
indications for PCI in men and women in the United Kingdom, with uptake
in women lagging behind that of men.
• Radial access in both men and women is independently associated with
lower 30-day mortality, in-hospital MACE and major bleeding
complications, and that the absolute decreases in crude event rates
associated with radial access are greatest in women.
• These findings suggest that radial access should be considered as the
preferred access site choice for PCI, particularly in women in whom the
greatest absolute reductions in adverse endpoints were observed.