Skip to main content
SpringerLink
Log in

Radial Versus Femoral Access for Percutaneous Coronary Intervention: Implications for Vascular Complications and Bleeding

  • Management of Acute Coronary Syndromes (R Mehran, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Since its advent over two decades ago, transradial access for cardiac catheterization and percutaneous intervention has evolved into a versatile and evidence-based approach for containing the risks of access-site bleeding and vascular complications without compromising the technical range or success associated with contemporary percutaneous coronary intervention (PCI). Early studies demonstrated reduced rates of vascular complications and access-site bleeding with radial-access catheterization but at the cost of increased access-site crossover and reduced procedural success. Contemporary data demonstrate that while the rates of major bleeding with femoral-access PCI in standard-risk cohorts have declined significantly over time, the transradial approach still retains significant advantages by way of reductions in vascular complications, length of stay, and enhanced patient comfort and patient preference over the femoral approach, while maintaining procedural success. Major adverse cardiovascular events and bleeding are lowest with the transradial approach when procedures are performed at high-volume radial centers, by experienced radial operators, or in the context of ST-segment elevation myocardial infarction. Choice of procedural anticoagulation appears to differentially impact access-site bleeding in transradial versus transfemoral PCI; however, non-access site bleeding remains a significant contributor to major bleeding in both groups. Despite abundant supporting data, adoption of transradial technique as the default strategy in cardiac catheterization in the United States has lagged behind many other countries. However, recent trends suggest that interest and adoption of the technique in the United States is growing at a brisker pace than previously observed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2–e220.

    Article  PubMed  Google Scholar 

  2. Sewell WH. Coronary arteriography by the Sones technique—Technical considerations. Am J Roentgenol. 1965;95:673–83.

    CAS  Google Scholar 

  3. Judkins MP. Selective coronary arteriography: I: a percutaneous transfemoral technique. Radiology. 1967;89:815–24.

    PubMed  CAS  Google Scholar 

  4. Amplatz K, Formanek G, Stranger P, et al. Mechanics of selective coronary artery catheterization via femoral approach. Radiology. 1967;89:1040–7.

    PubMed  CAS  Google Scholar 

  5. Ryan T. The coronary angiogram and its seminal contributions to cardiovascular medicine over five decades. Circulation. 2002;106:752–6.

    Article  PubMed  Google Scholar 

  6. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn. 1989;16:3–7.

    Article  PubMed  CAS  Google Scholar 

  7. Kiemeneij F, Laarman GJ. Percutaneous transradial artery approach for coronary stent implantation. Cathet Cardiovasc Diagn. 1993;30:173–8.

    Article  PubMed  CAS  Google Scholar 

  8. Kirtane AJ, Piazza G, Murphy SA, et al. Correlates of bleeding events among moderate- to high-risk patients undergoing percutaneous coronary intervention and treated with eptifibatide: Observations from the PROTECT-TIMI-30 trial. J Am Coll Cardiol. 2006;47:2374–9.

    Article  PubMed  CAS  Google Scholar 

  9. Feit F, Voeltz MD, Attubato MJ, et al. Predictors and impact of major hemorrhage on mortality following percutaneous coronary intervention from the REPLACE-2 trial. Am J Cardiol. 2007;100:1364–9.

    Article  PubMed  Google Scholar 

  10. Mehta SK, Frutkin AD, Lindsey JB, et al. Bleeding in patients undergoing percutaneous coronary intervention: the development of a clinical risk algorithm from the National Cardiovascular Data Registry. Circ Cardiovasc Interv. 2009;2:222–9.

    Article  PubMed  Google Scholar 

  11. Doyle BJ, Ting HH, Bell MR, et al. Major femoral bleeding complications after percutaneous coronary intervention. Incidence, predictors, and impact on long-term survival among 17,901 patients treated at the Mayo Clinic from 1994 to 2005. J Am Coll Cardiol Cardiovasc Interv. 2008;1:202–9.

    Google Scholar 

  12. Kinnaird TD, Stabile E, Mintz GS, et al. Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions. Am J Cardiol. 2003;92:930–5.

    Article  PubMed  Google Scholar 

  13. Ndrepepa G, Berger PB, Mehilli J, et al. Periprocedural bleeding and 1-year outcome after percutaneous coronary interventions: appropriateness of including bleeding as a component ofa quadruple end point. J Am Coll Cardiol. 2008;51:690–7.

    Article  PubMed  Google Scholar 

  14. Manoukian SV, Feit F, Mehran R, et al. Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY trial. J Am Coll Cardiol. 2007;49:1362–8.

    Article  PubMed  Google Scholar 

  15. Stone GW, Witzenbichler B, Guagliumi G, et al. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med. 2008;358:2218–30.

    Article  PubMed  CAS  Google Scholar 

  16. Eikelboom JW, Mehta SR, Anand SS, et al. Adverse impact of bleeding on prognosis inpatients with acute coronary syndromes. Circulation. 2006;114:774–82.

    Article  PubMed  Google Scholar 

  17. Rao SV, Eikelboom JA, Granger CB, et al. Bleeding and blood transfusion issues in patients with non-ST-segment elevation acute coronary syndromes. Eur Heart J. 2007;28:1193–204.

    Article  PubMed  Google Scholar 

  18. Arora N, Matheny ME, Sepke C, et al. Practices and complications of vascular closure devices and manual compression in patients undergoing elective transfemoral coronary procedures. Am Heart J. 2007;153:606211.

    Article  Google Scholar 

  19. Smilowitz NR, Kirtane AJ, Guiry M, et al. Practices and complications of vascular closure devices and manual compression in patients undergoing elective transfemoral coronary procedures. American Journal of Cardiology. 2012. In press.

  20. Applegate RJ, Sacrinty MT, Kutcher MA, et al. Trends in vascular complications after diagnostic cardiac catheterization and percutaneous coronary intervention via the femoral artery,1998 to 2007. J Am Coll Cardiol Cardiovasc Interv. 2008;1:317–26.

    Google Scholar 

  21. Vaitkus PT. A meta-analysis of percutaneous vascular closure devices after diagnostic catheterization and percutaneous coronary intervention. J Invasive Cardiol. 2004;16:243–6.

    PubMed  Google Scholar 

  22. Nikolsky E, Mehran R, Halkin A, et al. Vascular complications associated with arteriotomy closure devices in patients undergoing percutaneous coronary procedures: a meta-analysis. J Am Coll Cardiol. 2004;44:1200–9.

    PubMed  Google Scholar 

  23. Koreny M, Riedmuller E, Nikfardjam M, et al. Arterial puncture closing devices compared with standard manual compression after cardiac catheterization: systematic review and meta-analysis. J Am Med Assoc. 2004;291:350–7.

    Article  CAS  Google Scholar 

  24. Tavris DR, Dey S, Brecht-Gallauresi B, et al. Risk of local adverse events following cardiac catheterization by hemostasis device use– Phase II. J Invasive Cardiol. 2005;17:644–50.

    PubMed  Google Scholar 

  25. Sanborn TA, Ebrahimi R, Manoukian SV, et al. Impact of femoral vascular closure devices and antithrombotic therapy on access site bleeding in acute coronary syndromes: The Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. Circ Cardiovasc Interv. 2010;3:57–62.

    Article  PubMed  CAS  Google Scholar 

  26. Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. J Am Coll Cardiol Cardiovasc Interv. 2008;1:379–86.

    Google Scholar 

  27. Burzotta F, Trani C, Mazzari MA, et al. Vascular complications and access crossover in 10,676 transradial percutaneous coronary procedures. Am Heart J. 2012;163:230–8.

    Article  PubMed  Google Scholar 

  28. Dieter RS, Akef A, Wolff M. Eversion endarterectomy complicating radial artery access for left heart catheterization. Catheter Cardiovasc Interv. 2003;58(4):478–80.

    Article  PubMed  Google Scholar 

  29. Rhyne D, Mann T. Hand ischemia resulting from a transradial intervention: successful management with radial artery angioplasty. Catheter Cardiovasc Interv. 2010;76:383–6.

    Article  PubMed  Google Scholar 

  30. Stella PR, Kiemeneij F, Laarman GJ, et al. Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty. Catheter Cardiovasc Diagn. 1997;40:156–8.

    Article  CAS  Google Scholar 

  31. Pancholy S, Coppola J, Patel T, et al. Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHETstudy): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv. 2008;72:335–40.

    Article  PubMed  Google Scholar 

  32. Rao SV. Observations from a transradial registry. Our remedies oft in ourselves do lie. J Am Coll Cardiol Cardiovasc Interv. 2012;5:44–6.

    Google Scholar 

  33. • Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011; 377: 1409–20. This discusses the RIVAL trial.

    Article  PubMed  Google Scholar 

  34. Verheugt FWA, Steinhubl SR, Hamon M, et al. Incidence, prognostic impact, and influence of antithrombotic therapy on access and non access site bleeding in percutaneous coronary intervention. J Am Coll Cardiol Cardiovasc Interv. 2011;4:191–7.

    Google Scholar 

  35. Lee M, Liao H, Yang T, et al. Comparison of bivalirudin versus heparin plus glycoprotein IIb/IIIa inhibitors in patients undergoing an invasive strategy: A meta-analysis of randomized clinical trials. Int J Cardiol. 2011;152:369–74.

    Article  PubMed  Google Scholar 

  36. Hamon M, Rasmussen LH, Manoukian SV, et al. Choice of arterial access site and outcomes in patients with acute coronary syndromes managed with an early invasive strategy: the ACUITY trial. EuroIntervention. 2009;5:115–20.

    Article  PubMed  Google Scholar 

  37. Hamon M, Mehta S, Steg PG, et al. Impact of transradial and transfemoral coronary interventions on bleeding and net adverse clinical events in acute coronary syndromes. EuroIntervention. 2011;7:91–7.

    Article  PubMed  Google Scholar 

  38. Grinfeld L, Berrocal D, Rojas Matas C, Magni J, Belardi J. What is the most effective vascular approach for a diagnostic cardiac catheterization? A randomized trial using the femoral, brachial or radial approaches (abstract). J Am Coll Cardiol. 1996;27(Suppl A):901.

    Google Scholar 

  39. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. Am Heart J. 1999;138:430–6.

    Article  PubMed  CAS  Google Scholar 

  40. Mann JT, Cubeddu G, Schneider JE, et al. Right radial access for PTCA: a prospective study demonstrates reduced complications and hospital charges. J Invasive Cardiol. 1996;8:40–D.

    Google Scholar 

  41. Benit E, Missault L, Eeman T, et al. Brachial, radial or femoral approach for elective Palmaz-Schatz stent implantation: a randomized comparison. Cathet Cardiovasc Diagn. 1997;41:124–30.

    Article  PubMed  CAS  Google Scholar 

  42. Kiemeneij F, Laarman GJ, Odekerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol. 1997;29:1269–75.

    Article  PubMed  CAS  Google Scholar 

  43. Mann JT, Cubeddu G, Bowen J, et al. Stenting in acute coronary syndromes: a comparison of radial versus femoral access sites. J Am Coll Cardiol. 1998;32:572–6.

    Article  PubMed  CAS  Google Scholar 

  44. Monsegu J, Duriez P, Schiano P, et al. A randomized trial comparing the radial and the femoral approach for coronary angiography (abstr). Am J Cardiol. 2000;86(Suppl 8A):52I.

    Google Scholar 

  45. Louvard Y, Lefevre T, Allain A, Morice MC. Coronary angiography through the radial or the femoral approach: the CARAFE study. Catheter Cardiovasc Interv. 2001;52:181–7.

    Article  PubMed  CAS  Google Scholar 

  46. Gorge G, Kirstein M. Fiction and fact: diagnostic and interventional left heart catheterization using the radial artery or the right femoral artery approach (abstr). Eur Heart J. 2001;22(Suppl):512.

    Google Scholar 

  47. Moriyama Y, Saito T, Oshima S, et al. Comparison of the procedure duration of the coronary angiography between the radial and femoral approach with 4 French catheters (abstr). Circulation. 2002;106(SupplII):II693.

    Google Scholar 

  48. Saito S, Tanaka S, Hiroe Y, et al. Comparative study on transradial approach vs. transfemoral approach in primary stent implantation for patients with acute myocardial infarction: results of the Test for Myocardial Infarction by Prospective Unicenter Randomization for Access Sites (TEMPURA) trial. Catheter Cardiovasc Interv. 2003;59:26–33.

    Article  PubMed  Google Scholar 

  49. Louvard Y, Sabatier R, Benamer H, et al. A randomized comparison of transradial and transfemoral approaches for coronary angiography and PTCA in octogenarians (abstr). Am J Cardiol. 2003;92(Suppl6A):17L.

    Google Scholar 

  50. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004;44:349–56.

    Article  PubMed  Google Scholar 

  51. Tian J, Wang LX, Wang GG, et al. Coronary angiography transradial approach in gerontal patients. Chinese Journal of Gerontology. 2003;23:563–5.

    Google Scholar 

  52. Reddy BK, Brewster PS, Walsh T, et al. Randomized comparison of rapid ambulation using radial, 4 French femoral access, or femoral access with AngioSeal closure. Catheter Cardiovasc Interv. 2004;62:143–9.

    Article  PubMed  Google Scholar 

  53. Cantor WJ, Puley G, Natarajan MK, et al. Radial versus femoral accessforemergentpercutaneouscoronaryinterventionwithadjunctglycoproteinIIb/IIIa inhibition in acute myocardial infarction—the RADIAL-AMI pilot randomized trial. Am Heart J. 2005;150:543–9.

    Article  PubMed  CAS  Google Scholar 

  54. Achenbach S, Ropers D, Turan N, et al. Transradial versus transfemoral access for coronary angiography in elderly patients: comparison of procedural data and complication rates. J Am Coll Cardiol. 2005;45:A40.

    Google Scholar 

  55. Slagboom T, Kiemeneij F, Laarman GJ, et al. Outpatient coronary angioplasty: feasible and safe. Catheter Cardiovasc Interv. 2005;64:421–7.

    Article  PubMed  Google Scholar 

  56. Brasselet C, Tassan S, Nazeyrollas P, et al. Randomised comparisonof femoral versus radial approach for percutaneous coronaryintervention using abciximab in acute myocardial infarction: results ofthe FARMI trial. Heart. 2007;93:1556–61.

    Article  PubMed  CAS  Google Scholar 

  57. Lange HW, von Boetticher H. Randomized comparison of operator radiation exposure during coronary angiography and intervention by radial or femoral approach. Catheter Cardiovasc Interv. 2006;67:12–6.

    Article  PubMed  Google Scholar 

  58. Vazquez-Rodriguez JM, Calvino-Santos RA, Baz-Alonso JA, et al. Radial vs. femoral arterial access in emergent coronary interventions for acute myocardial infarction with ST segment elevation. J Am Coll Cardiol. 2007;49 Suppl 2:12B.

    Google Scholar 

  59. Chodor P, Kurek T, Sokal A, et al. Radial vs femoral approaches for PCI for patients with acute myocardial infarction. The RADIAMI prospective, randomized, single center trial. Eur Heart J. 2007;28:663.

    Article  Google Scholar 

  60. Bodi V, Sanchis J, Nunez J, et al. Left radial approach in daily practice. Results of a randomized study comparing femoral, right and left radial approaches. J Am Coll Cardiol Cardiovasc Interv. 2008;1(2 [Supplement B]):B94.

    Google Scholar 

  61. Li WM, Li Y, Zhao JY, et al. Safety and feasibility of emergent percutaneous coronary intervention with the transradial access inpatients with acute myocardial infarction. Chinese Medical Journal (Engl). 2007;120:598–600.

    Google Scholar 

  62. • Jolly SS, Amlani S, Hamon M, et al. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. American Heart Journal 2009;157:132–40. This discusses radial versus femoral access.

    Article  PubMed  Google Scholar 

  63. Chase AJ, Fretz EB, Warburton WP, et al. Association of the arterial access site at angioplasty with transfusion and mortality: the M.O.R.T.A.L study (Mortality benefit Of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg. Heart. 2008;94:1019–25.

    Article  PubMed  CAS  Google Scholar 

  64. Romagnoli E, Biondi-Zoccai G, Sangiorgi G, et al. Radial versus Femoral Randomized Investigation in ST Elevation Acute Coronary Syndrome - the RIFLE STEACS study. Presented at the Transcatheter Cardiovascular Therapeutics (TCT) Conference. San Francisco, CA; November 10, 2011.

  65. • Joyal D, Bertrand O, Rinfret S, et al. Meta-analysis of ten trials on the effectiveness of the radial versus the femoral approach in primary percutaneous coronary intervention. American Journal of Cardiology 2012; 109:813–8. This discusses the radial versus femoral approach in PCI.

    Article  PubMed  Google Scholar 

  66. Stone GW, Witzenbichler B, Guagliumi G, et al. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med. 2008;358:2218–30.

    Article  PubMed  CAS  Google Scholar 

  67. Généreux P, Mehran R, Palmerini T, et al. Radial access in patients with ST-segment elevation myocardial infarction undergoing primary angioplasty in acute myocardial infarction: the HORIZONS-AMI trial. EuroIntervention. 2011;7:905–16.

    Article  PubMed  Google Scholar 

  68. Johnman C, Pell JP, Mackay DF, et al. Clinical outcomes following radial versus femoral artery access in primary or rescue percutaneous coronary intervention in Scotland: retrospective cohort study of 4534 patients. Heart. 2012;98:552e557.

    Article  Google Scholar 

  69. Yatskar L, Selzer F, Feit F, et al. Access site hematoma requiring blood transfusion predicts mortality in patients undergoing percutaneous coronary intervention: Data from the national heart, lung, and blood institute Dynamic registry. Catheter Cardiovasc Interv. 2007;69:961–6.

    Article  PubMed  Google Scholar 

  70. • Doyle BJ, Rihal CS, Gastineau DA, et al. Bleeding, blood transfusion, and increased mortality after percutaneous coronary intervention: Implications for contemporary practice. Journal of the American College of Cardiology. 2009;53:2019–27. This discusses mortality after PCI.

    Article  PubMed  Google Scholar 

  71. Rao SV, Cohen MG, Kandzari DE, et al. The transradial approach to percutaneous coronary intervention. Historical perspective, current concepts, and future directions. J Am Coll Cardiol. 2010;55:2187–95.

    Article  PubMed  Google Scholar 

Download references

Disclosure

Conflicts of interest: S. Nathan: has served as a consultant to Medtronic, Boston Scientific, Merck, Daiichi-Sankyo, Ortho-McNeil and Volcano and has received research funding from Accumetrics; S.V. Rao: has served as a consultant to Terumo Medical, The Medicines Company, ZOLL, and Volcano.

Author information

Authors and Affiliations

  1. University of Chicago Medical Center, 5841 South Maryland Avenue, MC 5076, Section of Cardiology, Chicago, IL, 60637-1470, USA

    Sandeep Nathan

  2. Duke Clinical Research Institute, 508 Fulton Street (111A), Durham, NC, 27705, USA

    Sunil V. Rao

Authors
  1. Sandeep Nathan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sunil V. Rao
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sandeep Nathan.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Nathan, S., Rao, S.V. Radial Versus Femoral Access for Percutaneous Coronary Intervention: Implications for Vascular Complications and Bleeding. Curr Cardiol Rep 14, 502–509 (2012). https://doi.org/10.1007/s11886-012-0287-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11886-012-0287-5

Keywords

Search

Navigation