August 31, 2022

Clinical and Procedural Outcomes of Radial Versus Femoral Access for CTO PCI Evaluated in the PROGRESS-CTO Registry

August 31, 2022—In an observational study of patients who underwent chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in the PROGRESS-CTO registry, radial-only access was used in almost one-quarter of patients, with a lower rate of access site complications and similar technical success and major adverse cardiovascular event (MACE) rates as compared with femoral access. Results were published online by Simsek et al in Catheterization and Cardiovascular Interventions.

KEY FINDINGS

Radial-only access was used in 24% of patients.
Radial access was used more often in CTOs with more favorable angiographic characteristics.
As compared with femoral access, radial-only access was associated with a lower rate of access site complications, and technical success and MACE rates were similar.

Investigators used the PROGRESS-CTO database to collect patient-level data for CTO PCI procedures performed between 2012 and 2022 at experienced CTO PCI centers in seven countries. Patients were stratified by radial-only, radial/femoral, and femoral access.

Of 10,954 patients who underwent CTO PCI, 24% had radial-only access (12% single and 12% biradial), 29% had femoral-radial access, 15% had single femoral access, and 33% had bifemoral access. Patients who underwent radial access tended to be younger, male, and had significantly fewer comorbidities such as diabetes mellitus, prior heart failure, prior PCI, and/or prior coronary artery bypass graft surgery. As compared with femoral access, radial-only access was more often performed in patients with favorable angiographic characteristics (lower proximal cap ambiguity, moderate/severe proximal tortuosity and calcification, lower J-CTO [Multicenter CTO Registry of Japan] and PROGRESS-CTO scores).

After adjusting for multiple confounding variables, radial-only access was associated with a lower risk of access site complications (odds ratio [OR], 0.45; 95% CI, 0.22-0.91; P = .026) as compared with femoral access, and technical success (OR, 0.87; 95% CI, 0.74-1.04; P = .126) and MACE rates (OR, 0.65; 95% CI, 0.40-1.07; P = .087) were similar.

Limitations of this study included that PROGRESS-CTO is observational, adjustments for multiple statistical comparisons were not made, the lack of event adjudication by an independent committee, postprocedural patency of the radial artery was not assessed, the crossover rate for the access was not available, and that the operators were highly experienced in CTO PCI, noted the investigators.

CARDIAC INTERVENTIONS TODAY ASKS…

Study investigators Bahadir Simsek, MD, and Emmanouil Brilakis, MD, with the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation in Minneapolis, Minnesota, provided some insight into the results and their implications.

You noted that the use of radial access will likely increase based on the results of the recent FORT CTO study and American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions class 1A guideline recommendation for radial access PCI in acute coronary syndrome and stable ischemic heart disease. What are the ideal steps to achieving technical proficiency in radial access, as it is increasingly being used by more operators?

Achieving high success and low complication rates with both radial and especially femoral access is highly dependent on the training and experience of operators. For all CTO and complex PCI operators, we would recommend that they continue to obtain both femoral and radial access using state-of-the-art access techniques. Exclusive or near-exclusive use of a single access route may lead to gradual “atrophy” of the interventionalists’ skills in other access sites.

At 76%, femoral access was still the most common access used in this study. How do these results translate into real-world decision-making between femoral and radial access? When is femoral access still more likely to be used?

Although radial access can be used successfully in many CTO and other complex PCIs, femoral access remains essential, for example in highly complex cases, in patients who require larger guide catheters, and when radial access fails. Femoral/radial access is commonly used for CTO PCI.

What does the future study landscape look like to evaluate radial versus femoral access in complex PCI? What needs to be further determined?

We need to learn if state-of-the-art femoral access techniques (using ultrasound, fluoroscopy, and a micropuncture needle for access; obtaining an angiogram after femoral access; and using an arterial closure device) can be as good as radial access in vascular access complications. To this end, we have initiated the REBIRTH trial (NCT04077762), which is randomizing 3,266 patients without ST‐segment elevation myocardial infarction undergoing coronary angiography with possible PCI (non‐CTO) to either radial or state-of-the art femoral access.

Subscribe to our weekly newsletter.

Stay informed on the week's top stories including literature summaries, device approvals, guideline changes, and more. Plus, get our latest issues & supplements delivered to your inbox each month.