Radial access first for PCI in acute coronary syndrome

Are we propping up a straw man?

Radialer Zugang erstrangig für die PCI beim akuten Koronarsyndrom

Erfolgt hier eine Scheinargumentation?

Abstract

Coronary angiography and percutaneous coronary intervention (PCI) represent the recommended revascularization strategy for patients presenting with acute coronary syndrome (ACS). However, periprocedural bleeding events, of which up to 50% are related to the access site, remain an important complication of PCI and are associated with higher costs, prolonged hospital stays, and increased mortality. Several randomized trials have demonstrated that PCI performed via radial artery (RA) access is associated with a reduction in bleeding events, and perhaps a reduction in mortality compared with femoral artery (FA) access. As a result, current practice guidelines from the European Society of Cardiology and the Canadian Cardiovascular Society recommend that RA be the default strategy for PCI in patients presenting with ACS. The recently published Safety and Efficacy of Femoral Access vs. Radial Access in ST-Segment Elevation Myocardial Infarction (SAFARI-STEMI) trial challenges the benefits of a default RA approach in a contemporary setting where additional bleeding-reduction strategies (i.e., avoidance of glycoprotein IIb/IIIa inhibitors, routine use of bivalirudin for procedural anticoagulation, and vascular closure devices) were employed. In order to better understand the evidence that has shaped the current recommendations, we present a review of the background studies and major randomized trials comparing RA with FA in patients presenting with ACS.

Zusammenfassung

Für Patienten mit einem akuten Koronarsyndrom (ACS) stellen die Koronarangiographie und die perkutane Koronarintervention (PCI) die empfohlene Revaskularisierungsstrategie dar. Jedoch sind periprozedurale Blutungsereignisse, von denen bis zu 50% am Ort des Zugangs auftreten, weiterhin eine bedeutende Komplikation der PCI und mit höheren Kosten, längerer Krankenhausverweildauer und erhöhter Mortalität vergesellschaftet. Verschiedene randomisierte Studien ergaben, dass eine PCI, die über einen Zugang via A. radialis (RA) erfolgt, mit einer Verminderung der Blutungsereignisse einhergeht und möglicherweise mit einer Senkung der Mortalität im Vergleich zum Zugang via A. femoralis (FA). Daher wird in aktuellen Praxisleitlinien der European Society of Cardiology und der Canadian Cardiovascular Society der Zugang via RA als Standardstrategie für die PCI bei Patienten mit ACS empfohlen. Die kürzlich veröffentlichte Studie Safety and Efficacy of Femoral Access vs. Radial Access in ST-Segment Elevation Myocardial Infarction (SAFARI-STEMI) stellt die Vorteile eines Standardzugangs via RA in einer zeitgemäßen Situation infrage, in der zusätzliche blutungsvermindernde Strategien angewandt würden (d. h. Vermeidung von Glykoprotein-IIb/IIIa-Inhibitoren, Routineeinsatz von Bivalirudin zur prozeduralen Antikoagulation und Verwendung von Gefäßverschlusssystemen). Um die Evidenz besser zu verstehen, die Einfluss auf die aktuellen Empfehlungen hat, werden in der vorliegenden Übersichtsarbeit die Hintergrundstudien und die wesentlichen randomisierten Studien dargestellt, in denen die Zugänge via RA und FA bei Patienten mit ACS verglichen werden.

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Correspondence to Professor Michel Le May MD.

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J.A. Marbach, S. Alhassani, G. Wells and M. Le May declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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Marbach, J.A., Alhassani, S., Wells, G. et al. Radial access first for PCI in acute coronary syndrome. Herz (2020). https://doi.org/10.1007/s00059-020-04958-4

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Keywords

  • Revascularization
  • Percutaneous coronary intervention
  • Radial artery
  • Femoral artery
  • Mortality

Schlüsselwörter

  • Revaskularisierung
  • Perkutane Koronarintervention
  • A. radialis
  • A. femoralis
  • Mortalität