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Transradial Coronary Intervention-Radiant or Brilliant?

András Komócsi and Dániel Aradi.

We read with great interest the recently published review of Rao et al. regarding the clinical benefits of using the transradial approach for percutaneous coronary interventions (PCI). The paper outstandingly demonstrates how deeply a technical modification might influence our current clinical practice. Despite these benefits, the paper attracts the reader's attention to the low adoption rate of this technique that is primarily supplied by the fears and thoughts from the learning curve of the undevoted operators. In the current correspondence, we would like to extend the Rao et al. discussion with the findings of 2 recent observations.

Rao et al. cited and discussed 2 comprehensive meta-analyses of randomized comparisons between the transradial PCI and transfemoral PCI approaches. Although these studies demonstrated a significant reduction in bleeding- and access site-related complications, they failed to find a significant link between the frequency of adverse cardiovascular events or mortality. It should be noted that these analyses included studies performed predominantly in elective settings and thus the benefit of the higher-risk patients may have been concealed by the low-risk cases that may have formed the majority. In a recent meta-analysis of 12 studies involving 3,324 patients with ST-segment elevation myocardial infarction, we demonstrated that beyond the bleeding benefit, radial, when compared to transfemoral, approach reduced the risk of death, myocardial infarction, urgent revascularization, or stroke by 44% (odds ratio [OR]: 0.56 [95% confidence interval (CI): 0.39 to 0.79]; p = 0.001) and mortality by 46% (OR: 0.54 [95% CI: 0.33 to 0.86]; p = 0.01). Moreover, there were no differences in procedural times and in time to reperfusion between the 2 access routes. Fluoroscopic times were longer in cases of transradial PCI; however, there was significant heterogeneity among studies in these parameters.

Another trial that might add important observations to this topic is the RAPTOR (Radial Access versus conventional femoral PuncTure: Outcome and Resource effectiveness in a daily routine) study. The RAPTOR study was a prospective, randomized, single-center trial to compare radial versus femoral access in an unselected population. The study has demonstrated that an immediate, ad hoc switch to the transradial program is feasible for an interventional site with operators experienced in femoral access. The trial showed that transradial PCI was not associated with longer procedural or radiation times, nor with higher rates of access site failures. Procedural and fluoroscopic times and radiation doses were only greater in case of the diagnostic angiographies, but not for PCIs.

In conclusion, the use of transradial PCI is not only beneficial to reduce bleeding but also for ischemic complications and mortality in high-risk patients undergoing coronary interventions. The RAPTOR study demonstrates that it is safe and effective to change our clinical practice even from one day to the other. Longer fluoroscopic times might be attributable to the manipulation during the diagnostic phase that can be significantly reduced by training and experience.

J Am Coll Cardiol, 2010; 56:1265-1266.