Radial versus femoral access in ACS patients undergoing complex PCI is associated with consistent bleeding benefit and no excess of risks.

BACKGROUND

The comparative effectiveness of transradial (TRA) compared with transfemoral access (TFA) in acute coronary syndrome (ACS) patients undergoing complex percutaneous coronary intervention (PCI) remains unclear.

METHODS

Among 8,404 ACS patients in the Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX (MATRIX)-Access trial, 5,233 underwent noncomplex (TRA, n=2,590 and TFA, n=2,643) and 1,491 complex PCI (TRA, n=777 and TFA, n=714). Co-primary outcomes were major adverse cardiovascular events (MACE, the composite of all-cause mortality, myocardial infarction, or stroke) and the composite of MACE and BARC type 3-5 bleeding (net adverse cardiovascular events, NACE) at 30 days.

RESULTS

Rates of 30-day MACE (hazard ratio [HR]:0.94; 95% confidence interval [CI]:0.72-1.22) or NACE (HR:0.89; 95% CI:0.69-1.14) did not significantly differ between groups in the complex PCI group, whereas both primary endpoints were lower (HR:0.84; 95% CI:0.70-1.00, HR:0.83; 95% CI:0.70-0.98, respectively) with TRA among noncomplex PCI patients, with negative interaction testing (Pint 0.473 and 0.666, respectively). Access-site BARC type 3 or 5 bleeding was lower with TRA, consistently among complex (HR:0.18; 95% CI:0.05-0.63) and noncomplex (HR:0.41; 95% CI:0.20-0.85) PCI patients, whereas the former group had a greater absolute risk reduction of 1.7% (number needed to treat: 59) due to their higher absolute risk.

CONCLUSIONS

Among ACS patients, PCI complexity does not affect the comparative efficacy and safety of TRA versus TFA, whereas the absolute risk reduction of access-site major bleeding was greater with TRA compared with TFA in complex as opposed to noncomplex PCI.