Radial vs Femoral Approach in PCI With IABP Support
Radial vs Femoral Approach in PCI With IABP Support
Background The role of intraaortic balloon pump (IABP) during percutaneous coronary intervention (PCI) in high-risk acute patients remains debated. Device-related complications and the more complex patient management could explain such lack of clinical benefit. We aimed to assess the impact of transradial versus transfemoral access for PCI requiring IABP support on vascular complications and clinical outcome.
Methods We retrospectively analyzed 321 consecutive patients receiving IABP support during transfemoral (n = 209) or transradial (n = 112) PCI. Thirty-day net adverse clinical events (NACEs) (composite of postprocedural bleeding, cardiac death, myocardial infarction, target lesion revascularization, and stroke) were the primary end point, with access-related bleeding and hospital stay as secondary end points.
Results Cardiogenic shock and hemodynamic instability were the most common indications for IABP support. Cumulative 30-day NACE rate was 50.2%, whereas an access site–related bleeding occurred in 14.3%. Patients undergoing transfemoral PCI had a higher unadjusted rate of NACEs when compared with the transradial group (57.4% vs 36.6%, P < .01), mainly due more access-related bleedings (18.7% vs 6.3%, P < .01). Such increased risk of NACEs was confirmed after propensity score adjustment (hazard ratio 0.57 [0.4–0.9], P = .007), whereas hospital stay appeared comparable in the 2 groups.
Conclusions In this observational registry, high-risk patients undergoing PCI and requiring IABP support appeared to have fewer NACEs if transradial access was used instead of transfemoral, mainly due to fewer access-related bleedings. Given the inherent limitations of this retrospective work, including the inability to adjust for unknown confounders, further controlled studies are warranted to confirm or refute these findings.
Intraaortic balloon pump (IABP) support aims to improve oxygen supply and reduce cardiac oxygen demand by means of improved diastolic coronary flow and myocardial load, respectively. Thus, its use should be particularly indicated in case of left ventricular dysfunction complicating an ischemic insult to ameliorate ischemia and preserve myocardial viability.
Notwithstanding this intuitive rationale, the clinical impact of IABP remains controversial. Indeed, there is no evidence supporting its use in patients with acute ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock, whereas it is best avoided in patients with acute coronary syndrome (ACS) without hemodynamic instability, with the possible exception of high-risk patients undergoing percutaneous coronary intervention (PCI).
Furthermore, its use requires specific management by physician and nurses (eg, anticoagulation) to limit cerebrovascular complications, which could partly explain the lack of clinical benefit in randomized trials.
Recently, the RIVAL and RIFLE trials have reported a significant clinical benefit of transradial approach in STEMI patients undergoing early revascularization with evident reduction in access site hemorrhagic complications. Because the use of double transfemoral approach should be theoretically associated with an increased risk of vascular complications, the use of transradial plus transfemoral approach for the procedure in this high-risk subgroup could still be appealing. Thus, this study aimed to investigate the clinical impact of transradial approach in high-risk patient requiring periprocedural IABP support during PCI.
Abstract and Introduction
Abstract
Background The role of intraaortic balloon pump (IABP) during percutaneous coronary intervention (PCI) in high-risk acute patients remains debated. Device-related complications and the more complex patient management could explain such lack of clinical benefit. We aimed to assess the impact of transradial versus transfemoral access for PCI requiring IABP support on vascular complications and clinical outcome.
Methods We retrospectively analyzed 321 consecutive patients receiving IABP support during transfemoral (n = 209) or transradial (n = 112) PCI. Thirty-day net adverse clinical events (NACEs) (composite of postprocedural bleeding, cardiac death, myocardial infarction, target lesion revascularization, and stroke) were the primary end point, with access-related bleeding and hospital stay as secondary end points.
Results Cardiogenic shock and hemodynamic instability were the most common indications for IABP support. Cumulative 30-day NACE rate was 50.2%, whereas an access site–related bleeding occurred in 14.3%. Patients undergoing transfemoral PCI had a higher unadjusted rate of NACEs when compared with the transradial group (57.4% vs 36.6%, P < .01), mainly due more access-related bleedings (18.7% vs 6.3%, P < .01). Such increased risk of NACEs was confirmed after propensity score adjustment (hazard ratio 0.57 [0.4–0.9], P = .007), whereas hospital stay appeared comparable in the 2 groups.
Conclusions In this observational registry, high-risk patients undergoing PCI and requiring IABP support appeared to have fewer NACEs if transradial access was used instead of transfemoral, mainly due to fewer access-related bleedings. Given the inherent limitations of this retrospective work, including the inability to adjust for unknown confounders, further controlled studies are warranted to confirm or refute these findings.
Introduction
Intraaortic balloon pump (IABP) support aims to improve oxygen supply and reduce cardiac oxygen demand by means of improved diastolic coronary flow and myocardial load, respectively. Thus, its use should be particularly indicated in case of left ventricular dysfunction complicating an ischemic insult to ameliorate ischemia and preserve myocardial viability.
Notwithstanding this intuitive rationale, the clinical impact of IABP remains controversial. Indeed, there is no evidence supporting its use in patients with acute ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock, whereas it is best avoided in patients with acute coronary syndrome (ACS) without hemodynamic instability, with the possible exception of high-risk patients undergoing percutaneous coronary intervention (PCI).
Furthermore, its use requires specific management by physician and nurses (eg, anticoagulation) to limit cerebrovascular complications, which could partly explain the lack of clinical benefit in randomized trials.
Recently, the RIVAL and RIFLE trials have reported a significant clinical benefit of transradial approach in STEMI patients undergoing early revascularization with evident reduction in access site hemorrhagic complications. Because the use of double transfemoral approach should be theoretically associated with an increased risk of vascular complications, the use of transradial plus transfemoral approach for the procedure in this high-risk subgroup could still be appealing. Thus, this study aimed to investigate the clinical impact of transradial approach in high-risk patient requiring periprocedural IABP support during PCI.
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