1. Comparison of radial versus femoral access in patients undergoing invasive management for acute coronary syndromes: evidence from a systematic review and meta-analysis
G. Biondi-Zoccai,1 C. Moretti,1 F. Sciuto,1 P. Omedé,1 E. Cavallero,1 C. La Spina,1 V. Infantino,1 F. Colombo,1 E. Giraudi,1 E. Menditto,1 C. Iacovino,1 P. Agostoni,2 E. Romagnoli,3 M. Bollati,1 G. Trevi,1 I. Sheiban1
1University of Turin, Turin, Italy 2AZ Middelheim, Antwerp, Belgium; 3Policlinico Casilino, Rome, Italy

2. BACKGROUND
An invasive management encompassing coronary angiography and, when indicated, percutaneous coronary intervention (PCI), is recommended in most high-risk patients with acute coronary sindromes (ACS).
However, adverse events, especially local access site bleeding, are not uncommon.
The radial approach has been proposed as an alternative to the femoral access to minimize bleedings in ACS, but data are so far unclear.

3. AIM OF OUR WORK
We thus performed a comprehensive meta-analysis of randomized trials comparing radial vs femoral access in patients with ACS undergoing coronary angiography ± PCI.

4. METHODS
We performed a meta-analysis of all studies published up to April 2008 comparing radial versus femoral access in patients with ACS, by means of systematic database search (clinicaltrials.gov, Google Scholar, PubMed), and data appraisal.
The primary end-point was the occurrence of net adverse clinical events (NACE), defined as the composite of death, myocardial infarction (MI), repeat revascularization (ie major adverse cardiac events [MACE]) plus major bleeding.
Odds ratios (OR) and weighted mean differences (WMD) were computed by means of fixed-effect methods.

5. Pts with femoral access
INCLUDED STUDIES
Study
Year
Pts with radial access
Pts with femoral access
STEMI (%)
FARMI
2007 57
100%
Mann et al
1998 68 77
14%
RADIAL-AMI
2005 25
TEMPURA
2003 72

6. RESULTS
A total of 4 randomized controlled trials were included, enrolling a total of 458 patients (227 randomized to radial access and 231 randomized to femoral access).
Most (326) patients presented with acute ST-elevation myocardial infarction.
At hospital discharge, the radial access was associated with significant reductions in the rate of net adverse clinical events in comparison to the femoral access (24/227 [10.5%] vs 36/231 [15.6%], p=0.05).

7. RESULTS
Similarly beneficial yet statistically non-significant trends were also seen for death (7/227 [3.1%] vs 11/231 [4.8%]), major adverse cardiac events (21/227 [9.3%] vs 27/231 [11.7%]), and major bleedings (3/227 [1.3%] vs 9/231 [3.9%]; all p>0.05).
Radial access was also associated with a significant reduction in length of hospital stay (weighted mean difference days, p<0.001).

8. RISK OF DEATH
RISK OF MAJOR BLEEDING

9. RISK OF MACE
RISK OF NACE

10. RISK OF ACCESS SITE COMPLICATIONS
RISK OF PROCEDURAL FAILURE

11. TOTAL LENGTH OF HOSPITAL STAY IN DAYS
Review:
Radial vs femoral access in patients undergoing invasive management for acute coronary syndromes (1 August 2008)
Comparison:
01 Comparison of radial versus femoral access for acute coronary syndromes
Outcome:
07 Length of hospital stay
Study
Radial
Femoral
WMD (fixed)
WMD (fixed)
or sub-category N
Mean (SD) N
Mean (SD)
95% CI
95% CI
Mann 1998
(0.30) (0.50)
-1.50 [-1.63, -1.37]
TEMPURA 2003
(4.90) (9.50)
-1.70 [-4.15, 0.75]
RADIAL-AMI 2005
(1.00) (1.00)
0.00 [-0.55, 0.55]
FARMI 2007
(0.50) (0.40)
-0.30 [-0.47, -0.13]
Total (95% CI)
-1.00 [-1.10, -0.90]
Test for heterogeneity: Chi² = , df = 3 (P < ), I² = 97.8%
Test for overall effect: Z = (P < )
-10 -5 5 10
Favors radial
Favors femoral

12. CONCLUSIONS
The radial access should be considered as the first choice vascular approach in most patients with unstable coronary artery disease managed invasively, given the evident overall clinical benefits.
This holds even truer for those at higher risk of adverse events, such as the elderly, women and those undergoing rescue intervention for failed thrombolysis.

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