Does the Evidence Support a Radial Approach in Non-ST Elevation Acute Coronary Syndromes?

Introduction: Trans-radial access (TRA) for PCI has been consistently shown to reduce mortality and bleeding complications compared with trans-femoral access (TFA) in pts with STEMI. On the contrary the efficacy and the safety of TRA in NSTE-ACS is still matter of debate Hypothesis: The purpose of this study was to determine the potential clinical benefits of TRA in the NSTE-ACS patient population Methods: We compared outcomes of TRA versus TFA in a real world population of patients with NSTE-ACS drawn from the ISACS-TC registry (NCT01218776) The primary outcome was the incidence of all cause death and stroke at 30 days. The secondary outcome was the combined endpoint of periprocedural major complications (MI type 4, abrupt closure, loss of side branches, distal embolization and postPCI TIMI flow≤2). The incidence of nonCABG related major bleeding (TIMI definition) was also noted Results: Of 3127 NSTE ACS patients undergoing PCI 2047 (65.5%) underwent TRA, which was more likely to be employed among male sex and patients with lower-risk characteristics: patients were younger with a lower burden of risk factors. Patients undergoing TRA had significantly more periprocedural complications than those who received TFA (24.4% vs 8.6% p<0.001). The combined endpoint was driven mainly by the rate of noreflow phenomenon (24.4% vs 9.7%). After adjustment for baseline variables, the risk of periprocedural complications was attenuated but still remained significant between the radial and femoral groups (OR 3.63 CI: 2.52-5.22). There were significant differences in center experience: 1651 of the 2047 TRA procedures were performed by centers with high volume characteristics. There was heterogeneity in treatment effect in patients receiving TRA in centers with high versus medium/low volume characteristics. The risk of periprocedural complications was no longer significant after adjustment for center characteristics (OR 0.94 CI 0.52-1.68). The rate of the primary outcome was 1.6% in the TRA group compared with 2.2% in the TFA (adjusted OR 0.65 CI 0.33-1.29). The rate of nonCABG-related major bleeding at 30 days was 1.5% in the TRA group compared with 0.5% in the TFA group. Yet this rate was substantially lower in centers with high volume characteristics. (Adjusted for age and sex OR 0.25 CI 0.03-2.06). Conclusions: No significant differences in the combined outcome of 30 day mortality and ischemic stroke were seen between TRA and TFA approach in patients with NSTE-ACS undergoing PCI. TRA may be preferred in these patients only in centers with considerable experience.