Radial versus femoral access for coronary angiography and percutaneous coronary interventions in critically ill patients.

backgroundEvidence is lacking to appraise whether radial access should be preferred to femoral access for coronary angiography (CAG) in critically ill patients.

methodsPatients admitted to the medical intensive care unit (ICU) of a university hospital over a 5-year period and requiring CAG immediately before or during the ICU stay were retrospectively included. The average treatment effect of the arterial route used for CAG was assessed through a win-ratio methodology with propensity score (PS)-based inverse probability of treatment weighting (IPTW). The primary endpoint was a hierarchical composite outcome of (i) all-cause death, (ii) resuscitated cardiac arrest, (iii) stroke, (iv) myocardial infarction, (v) acute limb ischemia and/or need for vascular surgery on CAG access site and (vi) Bleeding Academic Research Consortium (BARC) type 3 major bleeding, all assessed at day 28. The relationship between access site and the likelihood of all-cause death at day 28 was investigated with a Cox proportional hazard model stratified on the occurrence of cardiac arrest before CAG and adjusted through PS-based IPTW.

resultsAmong the 235 included patients (116 with femoral access and 119 with radial access), 145 (61.7%) were admitted following cardiac arrest and 116 (49.4%) presented with cardiogenic shock at the time of CAG. The primary composite endpoint occurred in 63.4% of patients with femoral access and 47.7% of patients with radial access in IPT-weighted populations (absolute risk difference 15.6%, 95% confidence interval [CI] 1.4% to 29.8%, P = 0.03; win ratio for femoral versus radial access 0.62, 95% CI 0.40 to 0.98, P = 0.04). Access site complications were more frequent in patients with femoral access while major bleedings were similarly observed in both groups. Femoral access was not associated with day-28 mortality (adjusted hazard ratio 1.43, 95% CI 0.90 to 2.26, P = 0.13). Percutaneous coronary revascularisation and implantation of veno-arterial extra-corporeal membrane oxygenation, when required, were not hastened with femoral access.

conclusionIn this study, the use of a femoral rather than radial approach for CAG in critically ill patients was associated with a higher incidence of access site complications but did not correlate with the hazard of major bleeding or all-cause death at day 28.