U.S. Finally Shows Radial-Artery PCI Growth

LOS ANGELES – Radial-artery access for percutaneous coronary interventions finally took off in the Unites States starting about 3 years ago, rising from a steady rate of less than 2% of all American coronary interventions done through early 2009 to more than 11% of all coronary procedures by the third quarter of 2011, according to a nationwide registry.

Registry data from more than 2.2 million PCIs done during January 2007–September 2011 also confirmed better safety for PCI with a radial-artery approach, with bleeding and vascular complication rates substantially below those of patients who underwent PCI via a femoral approach. In addition, procedural success showed a small but statistically significant benefit in favor of radial entry for PCI, Dr. Dmitriy N. Feldman reported at the annual scientific sessions of the American Heart Association.

But these advantages seen in observational data plus the rising use of radial access come against a backdrop of radial access’ failure to show any safety or efficacy advantage over femoral access in the largest randomized trial to compare the two approaches, published in 2011.

"The biggest and best randomized, controlled trial that compared femoral and radial for PCI, the RIVAL [Radial Versus Femoral Access for Coronary Angioplasty and Interventions in patients with Acute Coronary Syndromes] trial, showed absolutely no difference in bleeding or clinical outcomes," commented Dr. Eric R. Bates, an interventional cardiologist and professor of medicine at the University of Michigan in Ann Arbor (Lancet 2011;377:1409-23). Seeing differences in the registry data reported by Dr. Feldman "is a classic observational-trial effect. It could all be because of confounding and selection bias," Dr. Bates said in an interview.

The registry data reported at the meeting also documented a continued split among U.S. cardiologists in their use of radial-artery PCI: 20% of the 1,315 U.S. hospitals that contributed data to the registry during the study years did not perform any radial-access procedures, while 13 hospitals (1% of the total) used radial-artery approaches for more than half the PCIs they performed, said Dr. Feldman, an interventional cardiologist at New York-Presbyterian Hospital and Weill Cornell Medical School in New York.

Results from a second study reported at the meeting confirmed the superior safety of radial-artery PCI compared with femoral-artery access in a review of more than 750 patients treated at Ohio State University before and after a program-wide switch to radial-artery access as the default approach for elective PCIs, said Dr. Quinn Capers IV, an interventional cardiologist at Ohio State in Columbus. His comparison of complication rates during a period when few patients underwent PCI by a radial approach with a period shortly after when half the patients had the radial approach showed that this changeover to radial use linked with a greater than 75% drop in the rate of post-PCI myocardial infarctions and cuts by about two-thirds in the rate of blood transfusions and the rate of major access-site complications, Dr. Capers said.

American use of radial-artery PCI began rising sharply in late 2009 because of a "tipping point at that time," commented Dr. Jennifer Tremmel, an interventional cardiologist at Stanford (Calif.) University. "It was driven by fellows. Our fellows [at Stanford University] can now do both radial and femoral access" equally well, which allows them to better match their approach to what works best for the patient and for the procedure the patient will undergo.

"Most coronary interventions today can be done through the radial artery, while other procedures, like transcatheter aortic-valve replacement, use devices that are too large to go through the radial," said Dr. Ian C. Gilchrist, an interventionalist and professor of medicine at Penn State Hershey (Pa.) Medical Center. "There is a best approach for each procedure, but as equipment gets smaller and smaller I think you’ll see less and less of a role for femoral access for routine coronary work.

"Once you get into a period of rapid uptake [with radial-access PCI] it continues until you get up to 70% or 80%," Dr. Gilchrist predicted. "My guess is that radial will continue to rise [in the United States] until it far exceeds the transfemoral approach. That’s been the experience worldwide.

"In the United States there was a 10-year love affair with closure devices; that’s probably why radial didn’t kick up right away. But closure devices are at least $300 apiece, and they have never been shown to make a difference in outcomes. In my mind, transradial is a game changer," Dr. Gilchrist said in an interview. "It’s not just a minor change in the access site. It allows you to really redesign the cath lab – you don’t need all the beds." And it provides a better platform for routinely performing elective PCIs on a same-day discharge basis.

"Femoral closure devices give operators a false sense of security. Statistics show that the femoral closure devices do not reduce complications," said Dr. Christopher J. White, an interventional cardiologist and medical director of the John Ochsner Heart & Vascular Institute in New Orleans. "The prevalence of radials will continue to increase, eventually reaching parity with [the usage rate in] Europe and South American, perhaps in 5-10 years," he said in an interview.

"I first used radial access when I practiced in the United Kingdom for 3 years, but when I returned to America in 1997 I had six partners who were all femoral-access doctors," Dr. White recalled. "Now, 15 years later, three of those doctors are predominantly radialists, two use it occasionally, and the sixth, the oldest, remains stubbornly an exclusive femoralist. It is hard to teach an old dog a new trick, particularly when PCI procedures can result in life-threatening complications. Why should an expert at femoral access become a novice at radial access?" Radial access "is not for every case, and perhaps not for every interventionalist, but younger cardiologists and trainees are the ones changing the balance. The next generation of interventionalists will be the radialists of the future," Dr. White predicted.

Interventionalists "who do 50 or 75 PCIs a year don’t have the time to retrain with radial, and there is no imperative for a 50-year old to switch to radial access to only do PCIs for another 5 or 10 years," said Dr. Bates. Ideally, "radial is something every interventionalist ought to learn to do – it’s a complimentary technique" to femoral access, but he agreed that it will primarily be the interventionalists who become proficient with radial access during training who will drive a change in American practice.

The data Dr. Feldman reported came from the CathPCI Registry of the National Cardiovascular Data Registry, organized and sponsored by the American College of Cardiology. During the nearly 5 years studied, the participating hospitals, about 70% of U.S. centers that perform PCI, treated 2,135,994 patients who underwent PCI via femoral-artery access, and 94,729 who had PCI with radial-artery access. Quarterly rates of radial-access use stood at 1.2% during early 2007, and remained below 2% through the first quarter of 2009, but then began to rise steadily, reaching the highest level so far, 11.4% of all PCIs, in the third quarter of 2011.

The data also showed notable regional variations in PCI access sites, with radial-artery access more widely used in northeastern states. By mid 2011, radial PCI represented about 20% of all PCIs done in the northeastern U.S. region, compared with rates that peaked at about 8%-10% in the West, Midwest, and South.

The analysis also showed that 94.7% of the radial cases and 93.8% of the femoral cases produced procedural success. Bleeding complications affected 2.8% of the radial-access patients, compared with 6.1% of the femoral-access patients. In a multivariate analysis that adjusted for several case-specific differences, PCI done through the radial artery led to a statistically significant 56% reduction in any bleeding complication and a significant 65% reduction in any vascular complication, and a significant 14% increase in procedural success compared with femoral access, Dr. Feldman reported.

Patient subgroups with the biggest reductions in bleeding complications from radial access compared with femoral access were women, patients with ST-elevation myocardial infarctions, and patients who were at least 75 years old.

The data reported by Dr. Capers came from a comparison of post-PCI complications among the 414 patients who underwent PCI at Ohio State during the first quarter of 2010, and the 343 patients who had PCIs performed during the fourth quarter of 2011. During the earlier period, 5% of patients treated with PCI at Ohio State had access via the radial artery, while at the end of 2011 50% of patients had radial-access PCI. This shift in PCI access started in 2010, when the seven attending cardiologists who perform PCIs at Ohio State agreed to all share a "radial-first mindset" for all elective procedures, Dr. Capers said.

The shift linked with statistically significant reductions in the rates of bleeding complications, blood transfusions, and major access-site complications during the first 72 hours following PCI, and also a reduction in post-PCI shock of about two-thirds that just missed statistical significance.

"These data are compelling" as a rationale for broader use of radial-access PCI, Dr. Capers said. "I think our use of radial access will continue to go up. We realize that we should do more radial cases. A lot is driven by the fellows [who know how to perform radial-access PCI] and by patients who ask for it," he said.

Patient preference as well as hospital preference may wind up being the most persuasive arguments in favor of the radial approach, Dr. Bates said.

"There is no question that radial access is more comfortable for patients, and it’s definitely the way to go for people who want same-day discharge from PCI. That’s terrific," and reason enough to favor radial access when it’s appropriate regardless of whether or not it is ever proven to cause less bleeding. Interventionalists are generally more comfortable sending a patient home the same day after elective PCI with radial access instead of femoral access, and that fact alone may be what drives future growth of the radial approach.

"More radial access will facilitate same-day discharge, and that will help save hospital beds for [all types of] patients who need overnight stays," Dr. Bates added. "A lot of hospitals today, like mine [at the University of Michigan], have many days when no spare beds are available. We’re always trying to figure out ways to speed patient turnover. Every hospital wants to grow its volume, and radial access will facilitate freeing hospital beds."

Dr. Feldman has been a consultant to Maquet Cardiovascular and Abbott Vascular. Dr. Capers said that he had no disclosures. Dr. Tremmel has received honoraria as a consultant to Abbott Vascular and Terumo Medical. Dr. Gilchrist has received honoraria from Terumo Medical. Dr. Bates and Dr. White said that they had no disclosures.

m.zoler@elsevier.com

On Twitter @mitchelzoler

LOS ANGELES – Radial-artery access for percutaneous coronary interventions finally took off in the Unites States starting about 3 years ago, rising from a steady rate of less than 2% of all American coronary interventions done through early 2009 to more than 11% of all coronary procedures by the third quarter of 2011, according to a nationwide registry.

Registry data from more than 2.2 million PCIs done during January 2007–September 2011 also confirmed better safety for PCI with a radial-artery approach, with bleeding and vascular complication rates substantially below those of patients who underwent PCI via a femoral approach. In addition, procedural success showed a small but statistically significant benefit in favor of radial entry for PCI, Dr. Dmitriy N. Feldman reported at the annual scientific sessions of the American Heart Association.

But these advantages seen in observational data plus the rising use of radial access come against a backdrop of radial access’ failure to show any safety or efficacy advantage over femoral access in the largest randomized trial to compare the two approaches, published in 2011.

"The biggest and best randomized, controlled trial that compared femoral and radial for PCI, the RIVAL [Radial Versus Femoral Access for Coronary Angioplasty and Interventions in patients with Acute Coronary Syndromes] trial, showed absolutely no difference in bleeding or clinical outcomes," commented Dr. Eric R. Bates, an interventional cardiologist and professor of medicine at the University of Michigan in Ann Arbor (Lancet 2011;377:1409-23). Seeing differences in the registry data reported by Dr. Feldman "is a classic observational-trial effect. It could all be because of confounding and selection bias," Dr. Bates said in an interview.

The registry data reported at the meeting also documented a continued split among U.S. cardiologists in their use of radial-artery PCI: 20% of the 1,315 U.S. hospitals that contributed data to the registry during the study years did not perform any radial-access procedures, while 13 hospitals (1% of the total) used radial-artery approaches for more than half the PCIs they performed, said Dr. Feldman, an interventional cardiologist at New York-Presbyterian Hospital and Weill Cornell Medical School in New York.

Results from a second study reported at the meeting confirmed the superior safety of radial-artery PCI compared with femoral-artery access in a review of more than 750 patients treated at Ohio State University before and after a program-wide switch to radial-artery access as the default approach for elective PCIs, said Dr. Quinn Capers IV, an interventional cardiologist at Ohio State in Columbus. His comparison of complication rates during a period when few patients underwent PCI by a radial approach with a period shortly after when half the patients had the radial approach showed that this changeover to radial use linked with a greater than 75% drop in the rate of post-PCI myocardial infarctions and cuts by about two-thirds in the rate of blood transfusions and the rate of major access-site complications, Dr. Capers said.

American use of radial-artery PCI began rising sharply in late 2009 because of a "tipping point at that time," commented Dr. Jennifer Tremmel, an interventional cardiologist at Stanford (Calif.) University. "It was driven by fellows. Our fellows [at Stanford University] can now do both radial and femoral access" equally well, which allows them to better match their approach to what works best for the patient and for the procedure the patient will undergo.

"Most coronary interventions today can be done through the radial artery, while other procedures, like transcatheter aortic-valve replacement, use devices that are too large to go through the radial," said Dr. Ian C. Gilchrist, an interventionalist and professor of medicine at Penn State Hershey (Pa.) Medical Center. "There is a best approach for each procedure, but as equipment gets smaller and smaller I think you’ll see less and less of a role for femoral access for routine coronary work.

"Once you get into a period of rapid uptake [with radial-access PCI] it continues until you get up to 70% or 80%," Dr. Gilchrist predicted. "My guess is that radial will continue to rise [in the United States] until it far exceeds the transfemoral approach. That’s been the experience worldwide.

"In the United States there was a 10-year love affair with closure devices; that’s probably why radial didn’t kick up right away. But closure devices are at least $300 apiece, and they have never been shown to make a difference in outcomes. In my mind, transradial is a game changer," Dr. Gilchrist said in an interview. "It’s not just a minor change in the access site. It allows you to really redesign the cath lab – you don’t need all the beds." And it provides a better platform for routinely performing elective PCIs on a same-day discharge basis.

"Femoral closure devices give operators a false sense of security. Statistics show that the femoral closure devices do not reduce complications," said Dr. Christopher J. White, an interventional cardiologist and medical director of the John Ochsner Heart & Vascular Institute in New Orleans. "The prevalence of radials will continue to increase, eventually reaching parity with [the usage rate in] Europe and South American, perhaps in 5-10 years," he said in an interview.

"I first used radial access when I practiced in the United Kingdom for 3 years, but when I returned to America in 1997 I had six partners who were all femoral-access doctors," Dr. White recalled. "Now, 15 years later, three of those doctors are predominantly radialists, two use it occasionally, and the sixth, the oldest, remains stubbornly an exclusive femoralist. It is hard to teach an old dog a new trick, particularly when PCI procedures can result in life-threatening complications. Why should an expert at femoral access become a novice at radial access?" Radial access "is not for every case, and perhaps not for every interventionalist, but younger cardiologists and trainees are the ones changing the balance. The next generation of interventionalists will be the radialists of the future," Dr. White predicted.

Interventionalists "who do 50 or 75 PCIs a year don’t have the time to retrain with radial, and there is no imperative for a 50-year old to switch to radial access to only do PCIs for another 5 or 10 years," said Dr. Bates. Ideally, "radial is something every interventionalist ought to learn to do – it’s a complimentary technique" to femoral access, but he agreed that it will primarily be the interventionalists who become proficient with radial access during training who will drive a change in American practice.

The data Dr. Feldman reported came from the CathPCI Registry of the National Cardiovascular Data Registry, organized and sponsored by the American College of Cardiology. During the nearly 5 years studied, the participating hospitals, about 70% of U.S. centers that perform PCI, treated 2,135,994 patients who underwent PCI via femoral-artery access, and 94,729 who had PCI with radial-artery access. Quarterly rates of radial-access use stood at 1.2% during early 2007, and remained below 2% through the first quarter of 2009, but then began to rise steadily, reaching the highest level so far, 11.4% of all PCIs, in the third quarter of 2011.

The data also showed notable regional variations in PCI access sites, with radial-artery access more widely used in northeastern states. By mid 2011, radial PCI represented about 20% of all PCIs done in the northeastern U.S. region, compared with rates that peaked at about 8%-10% in the West, Midwest, and South.

The analysis also showed that 94.7% of the radial cases and 93.8% of the femoral cases produced procedural success. Bleeding complications affected 2.8% of the radial-access patients, compared with 6.1% of the femoral-access patients. In a multivariate analysis that adjusted for several case-specific differences, PCI done through the radial artery led to a statistically significant 56% reduction in any bleeding complication and a significant 65% reduction in any vascular complication, and a significant 14% increase in procedural success compared with femoral access, Dr. Feldman reported.

Patient subgroups with the biggest reductions in bleeding complications from radial access compared with femoral access were women, patients with ST-elevation myocardial infarctions, and patients who were at least 75 years old.

The data reported by Dr. Capers came from a comparison of post-PCI complications among the 414 patients who underwent PCI at Ohio State during the first quarter of 2010, and the 343 patients who had PCIs performed during the fourth quarter of 2011. During the earlier period, 5% of patients treated with PCI at Ohio State had access via the radial artery, while at the end of 2011 50% of patients had radial-access PCI. This shift in PCI access started in 2010, when the seven attending cardiologists who perform PCIs at Ohio State agreed to all share a "radial-first mindset" for all elective procedures, Dr. Capers said.

The shift linked with statistically significant reductions in the rates of bleeding complications, blood transfusions, and major access-site complications during the first 72 hours following PCI, and also a reduction in post-PCI shock of about two-thirds that just missed statistical significance.

"These data are compelling" as a rationale for broader use of radial-access PCI, Dr. Capers said. "I think our use of radial access will continue to go up. We realize that we should do more radial cases. A lot is driven by the fellows [who know how to perform radial-access PCI] and by patients who ask for it," he said.

Patient preference as well as hospital preference may wind up being the most persuasive arguments in favor of the radial approach, Dr. Bates said.

"There is no question that radial access is more comfortable for patients, and it’s definitely the way to go for people who want same-day discharge from PCI. That’s terrific," and reason enough to favor radial access when it’s appropriate regardless of whether or not it is ever proven to cause less bleeding. Interventionalists are generally more comfortable sending a patient home the same day after elective PCI with radial access instead of femoral access, and that fact alone may be what drives future growth of the radial approach.

"More radial access will facilitate same-day discharge, and that will help save hospital beds for [all types of] patients who need overnight stays," Dr. Bates added. "A lot of hospitals today, like mine [at the University of Michigan], have many days when no spare beds are available. We’re always trying to figure out ways to speed patient turnover. Every hospital wants to grow its volume, and radial access will facilitate freeing hospital beds."

Dr. Feldman has been a consultant to Maquet Cardiovascular and Abbott Vascular. Dr. Capers said that he had no disclosures. Dr. Tremmel has received honoraria as a consultant to Abbott Vascular and Terumo Medical. Dr. Gilchrist has received honoraria from Terumo Medical. Dr. Bates and Dr. White said that they had no disclosures.

m.zoler@elsevier.com

On Twitter @mitchelzoler

LOS ANGELES – Radial-artery access for percutaneous coronary interventions finally took off in the Unites States starting about 3 years ago, rising from a steady rate of less than 2% of all American coronary interventions done through early 2009 to more than 11% of all coronary procedures by the third quarter of 2011, according to a nationwide registry.

Registry data from more than 2.2 million PCIs done during January 2007–September 2011 also confirmed better safety for PCI with a radial-artery approach, with bleeding and vascular complication rates substantially below those of patients who underwent PCI via a femoral approach. In addition, procedural success showed a small but statistically significant benefit in favor of radial entry for PCI, Dr. Dmitriy N. Feldman reported at the annual scientific sessions of the American Heart Association.

But these advantages seen in observational data plus the rising use of radial access come against a backdrop of radial access’ failure to show any safety or efficacy advantage over femoral access in the largest randomized trial to compare the two approaches, published in 2011.

"The biggest and best randomized, controlled trial that compared femoral and radial for PCI, the RIVAL [Radial Versus Femoral Access for Coronary Angioplasty and Interventions in patients with Acute Coronary Syndromes] trial, showed absolutely no difference in bleeding or clinical outcomes," commented Dr. Eric R. Bates, an interventional cardiologist and professor of medicine at the University of Michigan in Ann Arbor (Lancet 2011;377:1409-23). Seeing differences in the registry data reported by Dr. Feldman "is a classic observational-trial effect. It could all be because of confounding and selection bias," Dr. Bates said in an interview.

The registry data reported at the meeting also documented a continued split among U.S. cardiologists in their use of radial-artery PCI: 20% of the 1,315 U.S. hospitals that contributed data to the registry during the study years did not perform any radial-access procedures, while 13 hospitals (1% of the total) used radial-artery approaches for more than half the PCIs they performed, said Dr. Feldman, an interventional cardiologist at New York-Presbyterian Hospital and Weill Cornell Medical School in New York.

Results from a second study reported at the meeting confirmed the superior safety of radial-artery PCI compared with femoral-artery access in a review of more than 750 patients treated at Ohio State University before and after a program-wide switch to radial-artery access as the default approach for elective PCIs, said Dr. Quinn Capers IV, an interventional cardiologist at Ohio State in Columbus. His comparison of complication rates during a period when few patients underwent PCI by a radial approach with a period shortly after when half the patients had the radial approach showed that this changeover to radial use linked with a greater than 75% drop in the rate of post-PCI myocardial infarctions and cuts by about two-thirds in the rate of blood transfusions and the rate of major access-site complications, Dr. Capers said.

American use of radial-artery PCI began rising sharply in late 2009 because of a "tipping point at that time," commented Dr. Jennifer Tremmel, an interventional cardiologist at Stanford (Calif.) University. "It was driven by fellows. Our fellows [at Stanford University] can now do both radial and femoral access" equally well, which allows them to better match their approach to what works best for the patient and for the procedure the patient will undergo.

"Most coronary interventions today can be done through the radial artery, while other procedures, like transcatheter aortic-valve replacement, use devices that are too large to go through the radial," said Dr. Ian C. Gilchrist, an interventionalist and professor of medicine at Penn State Hershey (Pa.) Medical Center. "There is a best approach for each procedure, but as equipment gets smaller and smaller I think you’ll see less and less of a role for femoral access for routine coronary work.

"Once you get into a period of rapid uptake [with radial-access PCI] it continues until you get up to 70% or 80%," Dr. Gilchrist predicted. "My guess is that radial will continue to rise [in the United States] until it far exceeds the transfemoral approach. That’s been the experience worldwide.

"In the United States there was a 10-year love affair with closure devices; that’s probably why radial didn’t kick up right away. But closure devices are at least $300 apiece, and they have never been shown to make a difference in outcomes. In my mind, transradial is a game changer," Dr. Gilchrist said in an interview. "It’s not just a minor change in the access site. It allows you to really redesign the cath lab – you don’t need all the beds." And it provides a better platform for routinely performing elective PCIs on a same-day discharge basis.

"Femoral closure devices give operators a false sense of security. Statistics show that the femoral closure devices do not reduce complications," said Dr. Christopher J. White, an interventional cardiologist and medical director of the John Ochsner Heart & Vascular Institute in New Orleans. "The prevalence of radials will continue to increase, eventually reaching parity with [the usage rate in] Europe and South American, perhaps in 5-10 years," he said in an interview.

"I first used radial access when I practiced in the United Kingdom for 3 years, but when I returned to America in 1997 I had six partners who were all femoral-access doctors," Dr. White recalled. "Now, 15 years later, three of those doctors are predominantly radialists, two use it occasionally, and the sixth, the oldest, remains stubbornly an exclusive femoralist. It is hard to teach an old dog a new trick, particularly when PCI procedures can result in life-threatening complications. Why should an expert at femoral access become a novice at radial access?" Radial access "is not for every case, and perhaps not for every interventionalist, but younger cardiologists and trainees are the ones changing the balance. The next generation of interventionalists will be the radialists of the future," Dr. White predicted.

Interventionalists "who do 50 or 75 PCIs a year don’t have the time to retrain with radial, and there is no imperative for a 50-year old to switch to radial access to only do PCIs for another 5 or 10 years," said Dr. Bates. Ideally, "radial is something every interventionalist ought to learn to do – it’s a complimentary technique" to femoral access, but he agreed that it will primarily be the interventionalists who become proficient with radial access during training who will drive a change in American practice.

The data Dr. Feldman reported came from the CathPCI Registry of the National Cardiovascular Data Registry, organized and sponsored by the American College of Cardiology. During the nearly 5 years studied, the participating hospitals, about 70% of U.S. centers that perform PCI, treated 2,135,994 patients who underwent PCI via femoral-artery access, and 94,729 who had PCI with radial-artery access. Quarterly rates of radial-access use stood at 1.2% during early 2007, and remained below 2% through the first quarter of 2009, but then began to rise steadily, reaching the highest level so far, 11.4% of all PCIs, in the third quarter of 2011.

The data also showed notable regional variations in PCI access sites, with radial-artery access more widely used in northeastern states. By mid 2011, radial PCI represented about 20% of all PCIs done in the northeastern U.S. region, compared with rates that peaked at about 8%-10% in the West, Midwest, and South.

The analysis also showed that 94.7% of the radial cases and 93.8% of the femoral cases produced procedural success. Bleeding complications affected 2.8% of the radial-access patients, compared with 6.1% of the femoral-access patients. In a multivariate analysis that adjusted for several case-specific differences, PCI done through the radial artery led to a statistically significant 56% reduction in any bleeding complication and a significant 65% reduction in any vascular complication, and a significant 14% increase in procedural success compared with femoral access, Dr. Feldman reported.

Patient subgroups with the biggest reductions in bleeding complications from radial access compared with femoral access were women, patients with ST-elevation myocardial infarctions, and patients who were at least 75 years old.

The data reported by Dr. Capers came from a comparison of post-PCI complications among the 414 patients who underwent PCI at Ohio State during the first quarter of 2010, and the 343 patients who had PCIs performed during the fourth quarter of 2011. During the earlier period, 5% of patients treated with PCI at Ohio State had access via the radial artery, while at the end of 2011 50% of patients had radial-access PCI. This shift in PCI access started in 2010, when the seven attending cardiologists who perform PCIs at Ohio State agreed to all share a "radial-first mindset" for all elective procedures, Dr. Capers said.

The shift linked with statistically significant reductions in the rates of bleeding complications, blood transfusions, and major access-site complications during the first 72 hours following PCI, and also a reduction in post-PCI shock of about two-thirds that just missed statistical significance.

"These data are compelling" as a rationale for broader use of radial-access PCI, Dr. Capers said. "I think our use of radial access will continue to go up. We realize that we should do more radial cases. A lot is driven by the fellows [who know how to perform radial-access PCI] and by patients who ask for it," he said.

Patient preference as well as hospital preference may wind up being the most persuasive arguments in favor of the radial approach, Dr. Bates said.

"There is no question that radial access is more comfortable for patients, and it’s definitely the way to go for people who want same-day discharge from PCI. That’s terrific," and reason enough to favor radial access when it’s appropriate regardless of whether or not it is ever proven to cause less bleeding. Interventionalists are generally more comfortable sending a patient home the same day after elective PCI with radial access instead of femoral access, and that fact alone may be what drives future growth of the radial approach.

"More radial access will facilitate same-day discharge, and that will help save hospital beds for [all types of] patients who need overnight stays," Dr. Bates added. "A lot of hospitals today, like mine [at the University of Michigan], have many days when no spare beds are available. We’re always trying to figure out ways to speed patient turnover. Every hospital wants to grow its volume, and radial access will facilitate freeing hospital beds."

Dr. Feldman has been a consultant to Maquet Cardiovascular and Abbott Vascular. Dr. Capers said that he had no disclosures. Dr. Tremmel has received honoraria as a consultant to Abbott Vascular and Terumo Medical. Dr. Gilchrist has received honoraria from Terumo Medical. Dr. Bates and Dr. White said that they had no disclosures.

m.zoler@elsevier.com

On Twitter @mitchelzoler