By Steven L. Goldberg, MD
What are the implications that two trials suggested a mortality benefit when the radial approach was used to access the arterial system during a STEMI?
Although the overall finding of the RIVAL trial of radial versus femoral approach for percutaneous coronary intervention in patients presenting with either STEMI or NSTEMI was negative, the most striking finding was a statistically significant 59% mortality benefit favoring the radial approach in the group with an ST elevation myocardial infarction. Strikingly similarly, the RIFLE-STEACS trial also showed a 43% mortality benefit in patients undergoing PCI via the radial rather than the femoral route. Even though this was also a subgroup, in this case it is consistent with the primary endpoint of the trial, which demonstrated a significant reduction in the combined endpoint of cardiac death, myocardial infarction, stroke, target lesion revascularization and non-CABG bleeding, at thirty days in patients presenting with STEMI randomly assigned to radial versus femoral intervention. Interestingly, of these components, only cardiac death was significantly reduced, reminiscent of the specific mortality reduction in RIVAL. Is this sufficient data to recommend the radial approach for all patients undergoing primary PCI for STEMI’s?
What happens to the interventional cardiology landscape if such a trial confirms a mortality benefit for patients undergoing primary PCI for STEMI. This would invariably make it a Class I Guideline recommendation to use radial artery access (when feasible) for patients presenting with a STEMI. This would require all interventional cardiologists, and cath labs, who treat STEMI patients to become not only experienced, but facile in radial artery access for PCI. Although several studies have suggested that door to balloon time is not affected by vascular access choice, those studies have predominantly been done using operators with extensive radial artery access experience.
In order for operators to become proficient in radial artery approach for STEMIs, a significant number of the non-STEMI cases will need to be done via radial access. There will have to a major shift in training programs as well, to ensure that those in training develop appropriate experience in the more challenging use of the radial artery for access. Thus, such a study could be disruptive towards the practice of invasive and interventional cardiology, leading to a wholesale shift from the femoral approach for coronary artery procedures, to the radial artery approach. Given that currently only a minority of coronary cases are done via the radial artery access, at least in the US, this could have a major impact on how interventional cardiologists practice their craft.
Read Dr. Goldberg’s full editorial in the May issue of the Journal of Invasive Cardiology: Should We Abandon Femoral Access for STEMIs? J INVASIVE CARDIOL 2013;25(5):210
Dr. Goldberg is the Director of Cardiac Catheterization Laboratory at the University of Washington Medical Center in Seattle, Washington where he is a Clinical Associate Professor of Medicine. He is also the Chief Clinical Officer of Cardiac Dimensions, Inc He is a fellow in the Society of Cardiovascular Angiography and Intervention, as well as in the American College of Cardiology. Email: firstname.lastname@example.org