We analyzed a total of 11,555 cases of cardiac catheterization with the indication of AMI (NSTEMI and STEMI) performed during the study period, comprised of 4,895 (42.4%) performed via radial approach and 6,660 (57.6%) via the femoral approach. Unlike other 'real-world' registry, we included significantly large numbers of radial cases for comparison. Three thousand eight hundred (32.9%) cases were performed for NSTEMI while 7,755 (67.1%) cases for STEMI.
Patient’s baseline characteristics
Consistent with previously published reports from NCVD-PCI registry, our cohort of patients are generally much younger than reports from other parts of the world by approximately 10 years. (12,14)There were significantly more old and female patients subjected to the femoral approach during cardiac catheterization likely because they tend to have difficult and complex vasculatures. In patients with higher BMI and taller, it was more commonly performed via a radial approach. However, patients with co-morbidities namely diabetes mellitus, hypertension, previous stroke, heart failure, and chronic kidney disease were more likely to received cardiac catheterization via femoral access. More details of the patient's baseline characteristics are summarized in Table 1.
Table 1: Baseline characteristics
Characteristics
|
Radial, n (%)
|
Femoral, n (%)
|
p-value
|
Age (year, mean ± SD)
|
55.2 ± 10.5
|
56.7 ± 11.1
|
<0.001a
|
Gender
Male
Female
|
4368 (89.2)
527 (10.8)
|
5507 (82.7)
1153 (17.3)
|
<0.001
|
Ethnicity
Malay
Chinese
Indian
Others
|
2452 (50.1)
1068 (21.8)
816 (16.7)
555 (11.3)
|
3485 (52.4)
1372 (20.6)
1466 (22.0)
334 (5.0)
|
<0.001
|
BMI (kg/m2, median)
|
26.0
|
25.7
|
0.027
|
Height (cm, mean ± SD)
|
164.1 ± 8.0
|
163.0 ± 8.6
|
<0.001
|
Smoking status
Never/Former smoker
Current smoker
|
2547 (58.4)
1817 (41.6)
|
3667 (63.3)
2123 (36.7)
|
<0.001
|
Medical history
Diabetes mellitus
Hypertension
Dyslipidemia
Cerebrovascular disease
Heart failure
Chronic kidney disease
Peripheral vascular disease
|
1848 (40.1)
3013 (65.0)
2912 (65.5)
50 (1.1)
139 (2.9)
99 (2.1)
28 (0.6)
|
2896 (47.0)
4218 (68.2)
3868 (65.8)
144 (2.3)
303 (4.8)
446 (7.1)
42 (0.7)
|
<0.001
0.001
0.759
<0.001
<0.001
<0.001
0.623
|
Lesion characteristics and procedural data
Multi-vessels PCI was more likely to be performed via the femoral approach as compared to the radial approach. However, in contrast to the usual belief, the lesions performed via the femoral approach were not more complex than the one treated via the radial approach. The rate of type B2 and C lesions, as well as chronic total occlusion treated via either approach, were similar (Table 2).
Table 2: Lesion characteristics and procedural data
Variable
|
Radial, n (%)
|
Femoral, n (%)
|
p-value
|
Single vessels
Multi Vessels
|
1663 (55.7)
1323 (44.3)
|
2180 (49.4)
2234 (50.6)
|
<0.001
|
AHA/ACC lesion type
A/B1
B2/C
|
1896 (40.6)
2775 (59.4)
|
2483 (39.0)
3878 (61.0)
|
0.096
|
Chronic total occlusion
|
267 (5.6)
|
381 (5.9)
|
0.538
|
Type of devices
BMS
DES
Others
|
1171 (26.7)
2750 (62.7)
465 (10.6)
|
2267 (38.8)
3040 (52.0)
538 (9.2)
|
<0.001
|
POBA only
|
174 (3.6)
|
308 (4.7)
|
0.004
|
Fluoroscopy time, (median(s))
|
14.5
|
14.5
|
0.859
|
Contrast volume,
(mean ± SD)
|
161.9 ± 65.10
|
173.0 ± 70.54
|
<0.001
|
Clinical presentation
There were numerically more cases of PCI performed for STEMI as compared to NSTEMI in both groups. Among the STEMI cases, a proportionally higher percentage of patients presented with Killip class 3 and 4 underwent femoral approached PCI. In the event of failed thrombolysis, the radial approach was favored possibly due to presumably lower bleeding risk. Other details were listed in Table 3.
Table 3: Clinical presentation of PCI procedures
Variable
|
Radial, n (%)
|
Femoral, n (%)
|
p-value
|
Clinical presentation
STEMI
NSTEMI
|
3279 (67.0)
1616 (33.0)
|
4476 (67.2)
2184 (32.8)
|
0.803
|
Killip classification
Class 1 & 2
Class 3 & 4
|
2485 (94.5)
144 (5.5)
|
3064 (80.7)
733 (19.3)
|
<0.001
|
PCI status
Rescue
Primary
Facilitated
Delayed
|
984 (76.1)
77 (6.0)
9 (0.7)
223 (17.2)
|
1735 (68.5)
597 (23.6)
18 (0.7)
183 (7.2)
|
<0.001
|
Kidney function*
CKD
Non-CKD
|
99 (2.1)
4656 (97.9)
|
446 (7.1)
5869 (92.9)
|
<0.001
|
*CKD GFR < 60 ml/min/1.73m2, non-CKD GFR ≥ 60 ml/min/1.73m2
Procedural complications and outcomes
In terms of vascular complications, more bleeding was encountered during the femoral approach PCI as compared to radial (Table 4). On the other hand, more cases of general complications occurred in the femoral group possibly due to higher risk patient's characteristics. Composite in-hospital complications (vascular complications, MACE, and death) were significantly more frequent in the femoral group than in the radial group (Table 5). Patients with MI undergoing PCI via the femoral approach showed nearly 8 times higher risk of death, 3 times higher risk of developing MACE and doubled the risk of getting vascular complications as compared to their radial counterpart (Table 6).
Table 4: Procedural complications
Complications
|
Radial, n (%)
|
Femoral, n (%)
|
p-value
|
Vascular complications
Bleeding
Access site occlusion
Dissection
Pseudoaneurysm
|
15 (0.3)
2 (0.0)
4 (0.1)
0 (0.0)
|
53 (0.8)
5 (0.1)
8 (0.1)
3 (0.1)
|
0.001
0.706
0.523
0.267
|
General complications
Periprocedural MI
Emergency PCI
Bail-out CABG
Cardiogenic shock
Arrhythmia (VT/VF/Brady)
Heart Failure
Renal Impairment
|
42 (0.9)
16 (0.3)
3 (0.1)
9 (0.2)
16 (0.3)
4 (0.1)
5 (0.1)
|
70 (1.1)
78 (1.2)
4 (0.1)
130 (2.0)
139 (2.1)
20 (0.3)
64 (1.0)
|
0.285
<0.001
1.000
<0.001
<0.001
0.011
<0.001
|
TIA/Stroke
|
3 (0.1)
|
7 (0.1)
|
0.533
|
Tamponade
|
0 (0.0)
|
9 (0.1)
|
0.013
|
Table 5: In-hospital complications
Complications
|
Radial, n (%)
|
Femoral, n (%)
|
p-value
|
Vascular complications*
|
25 (0.4)
|
80 (1.1)
|
<0.001
|
MACE**
|
74 (1.3)
|
352 (4.7)
|
<0.001
|
Death
|
41 (0.7)
|
482 (6.4)
|
<0.001
|
*vascular complications included bleeding, access site occlusion, loss of distal pulse, dissection, pseudoaneurysm
**MACE (major adverse cardiovascular events) included periprocedural MI, bail-out CABG, cardiogenic shock, arrhythmia, TIA/stroke, cardiac tamponade, and heart failure.
Table 6: Adjusted odds ratios of developing in-hospital complications after trans-femoral PCI compared to the trans-radial approach.
Events
|
Adjusted OR*
|
95% confidence interval
|
P-value
|
Death
|
8.21
|
5.38-12.54
|
<0.001
|
MACE
|
3.39
|
2.51-4.58
|
<0.001
|
Vascular complications
|
1.79
|
1.01-3.16
|
0.047
|
*Adjusted for gender, race, age, smoking status, diabetes, hypertension, dyslipidemia, CVA, Types of ACS, renal failure, heart failure