JACC: CARDIOVASCULAR INTERVENTIONS

2008 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER INC.

VOL. 1, NO. 4, 2008

ISSN 1936-8798/08/$34.00
DOI: 10.1016/j.jcin.2008.05.007

Trends in the Prevalence and Outcomes of Radial

and Femoral Approaches to Percutaneous
Coronary Intervention
A Report From the National Cardiovascular Data Registry
Sunil V. Rao, MD, FACC,* Fang-Shu Ou, MS,* Tracy Y. Wang, MD, MS,*
Matthew T. Roe, MD, MHS, FACC,* Ralph Brindis, MD, MPH, FACC,
John S. Rumsfeld, MD, PHD, FACC, Eric D. Peterson, MD, MPH, FACC*
Durham, North Carolina; Oakland, California; and Denver, Colorado
Objectives Our goal was to compare trends in the prevalence and outcomes of the radial and femoral approaches to percutaneous coronary intervention (PCI) in contemporary clinical practice.
Background There are few current data on the use and outcomes of the radial approach to PCI
(r-PCI) in clinical practice.
Methods Data from 593,094 procedures in the National Cardiovascular Data Registry (606 sites;
2004 to 2007) were analyzed to evaluate trends in use and outcomes of r-PCI. Logistic regression
was used to evaluate the adjusted association between r-PCI and procedural success, bleeding complications, and vascular complications. Outcomes in elderly patients, women, and patients with
acute coronary syndrome were specically examined.
Results Although the proportion of r-PCI procedures has recently increased, it only accounts for
1.32% of total procedures (n 7,804). Compared with the femoral approach, the use of r-PCI was
associated with a similar rate of procedural success (adjusted odds ratio: 1.02 [95% condence interval: 0.93 to 1.12]) but a signicantly lower risk for bleeding complications (odds ratio: 0.42 [95% condence interval: 0.31 to 0.56]) after multivariable adjustment. The reduction in bleeding complications was more pronounced among patients 75 years old, women, and patients undergoing PCI
for acute coronary syndrome.
Conclusions The use of r-PCI is rare in contemporary clinical practice, but it is associated with a
rate of procedural success similar to the femoral approach and with lower rates of bleeding and
vascular complications, even among high-risk groups. These results suggest that wider adoption of
r-PCI in clinical practice may improve the safety of PCI. (J Am Coll Cardiol Intv 2008;1:379 86)
2008 by the American College of Cardiology Foundation

From *The Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Oakland Kaiser Hospital,
Oakland, California; and the Denver VA Medical Center, Denver, Colorado. This analysis was funded by the National
Cardiovascular Data Registry.
Manuscript received February 1, 2008; revised manuscript received May 5, 2008, accepted May 18, 2008.

380

Rao et al.
Trends in Radial and Femoral Approaches to PCI

Percutaneous coronary intervention (PCI) can be performed

via the femoral, brachial, or radial arteries. The femoral
approach traditionally has been the primary approach for many
operators, but is associated with a bleeding or vascular complication rate of up to 10% in some series (1). Given the decline
in post-PCI ischemic events over time (2), reduction in
bleeding risk has taken on new significance (3,4). A prior study
using data from a large registry found that access site hematomas large enough to require transfusion are associated with
an increased risk of adverse events, including mortality (5). In
this context, randomized trials comparing the femoral approach to percutaneous coronary intervention (f-PCI) with the
radial approach (r-PCI) have shown that the rate of vascular
and bleeding complications is significantly lower with the
radial approach (6 8). Despite these data, it is unclear how
often the radial approach is used in clinical practice and
whether the benefits seen in clinAbbreviations
ical trials translate to the wider
and Acronyms
population of patients undergoing
ACC American College of
PCI. Accordingly, we used data
Cardiology
from the National Cardiovascular
ACS acute coronary
Data Registry (NCDR) to examsyndrome
ine the prevalence of r-PCI and to
f-PCI femoral approach to
compare procedural success and
percutaneous coronary
in-hospital complications between
intervention
r-PCI and f-PCI. As prior studies
NCDR National
have shown that elderly patients,
Cardiovascular Data Registry
women, and patients with acute
NSTE ACS nonST-segment
coronary syndrome (ACS) are at
elevation acute coronary
syndrome
higher risk for bleeding complications (9,10), we specifically exPCI percutaneous
coronary intervention
plored trends in the use of r-PCI
r-PCI radial approach to
over time and corresponding outpercutaneous coronary
comes among patients age 75
intervention
years versus 75 years, female
STEMI ST-segment
versus male patients, and patients
elevation myocardial
with stable angina versus those
infarction
with ACS.

Methods
Study population. The NCDR, which is cosponsored by

the American College of Cardiology (ACC) and the

Society for Cardiovascular Angiography and Interventions, has been described previously (11). The NCDR
catalogs clinical data and outcomes in PCI procedures
that are gathered from over 600 sites across the U.S. Data
are entered into NCDR-certified databases at participating institutions and exported in a standard format to a
common database at Heart House (Washington, DC);
only institutions whose submissions meet quality criteria
for data reporting are included. The definitions of all
variables are prospectively defined by a committee of the

JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 1, NO. 4, 2008

AUGUST 2008:379 86

NCDR. An auditing program ensures the validity of

collected data.
For the purpose of this analysis, we included the first PCI
procedure performed in any individual patient during a
qualifying hospitalization between January 2004 and March
2007. The dataset comprised 725,549 procedures from 637
hospitals. From this, we excluded nonindex PCIs (n
18,745 procedures); any PCI involving an access site other
than the femoral or radial artery (n 6,991 procedures);
any emergency or salvage procedures, defined as procedures performed for ongoing myocardial ischemia or
infarction, pulmonary edema requiring intubation, or
shock; or if cardiopulmonary resuscitation was being
performed on a patient en route to the catheterization
laboratory (n 106,407); and procedures from any
hospitals performing fewer than 30 PCIs during the
study period due to inability to obtain stable estimates of
the proportion of r-PCI procedures at these institutions
(n 312 procedures).
Denitions and end points. Vascular access site (radial or
femoral) is defined in the NCDR as the site of successful
vascular entry; failed attempts are not captured. The primary
outcomes examined were the incidence of procedural success (defined as residual stenosis 50% with Thrombolysis
In Myocardial Infarction [TIMI] flow grade 2, and 20%
decrease in stenosis severity in all lesions attempted), bleeding complications (defined as access site bleeding, retroperitoneal bleeding, gastrointestinal bleeding, genitourinary
bleeding, or other bleeding), and vascular complications
(defined as access site occlusion, peripheral embolization,
arterial dissection, arterial pseudoaneurysm, or arteriovenous fistula). All bleeding end points in the NCDR are
further defined as requiring transfusion and/or prolonging
the hospital stay, and/or causing a drop in hemoglobin 3.0
g/dl. Hematomas 10 cm for femoral access or 2 cm for
radial access also qualify as access site bleeding. Access site
occlusion is defined in the database as total obstruction of
the artery, typically by thrombus (but may have other
causes), usually at the site of access requiring surgical repair.
Occlusions may be accompanied by absence of palpable or
Doppler pulse. Peripheral embolization is defined as a loss
of distal pulse, pain, and/or discoloration of the extremities
(especially the toes). Dissection is defined as a disruption of
an arterial wall resulting in splitting and separation of the
intimal layers; pseudoaneurysm is defined as the occurrence
of a disruption and dilation of the arterial wall without
identification of the arterial wall layers at the site of the
catheter entry demonstrated by arteriography or ultrasound.
Arteriovenous fistula is defined as a connection between the
access artery and the accompanying vein that is demonstrated by arteriography or ultrasound.
Statistical analysis. The prevalence of r-PCI was calculated
for the overall population as well as for each hospital.
Hospitals then were grouped by their percentage of r-PCI

Rao et al.
Trends in Radial and Femoral Approaches to PCI

JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 1, NO. 4, 2008

AUGUST 2008:379 86

procedures. For descriptive analyses, we compared baseline

characteristics, treatment profiles, procedure use, and clinical outcomes between r-PCI and f-PCI. Continuous variables are presented as medians with interquartile percentiles;
categorical variables are expressed as percentages. To test for
independence of a patients baseline characteristics, inhospital care patterns, and outcomes with respect to receiving r-PCI, Mann-Whitney Wilcoxon nonparametric tests
were used for continuous variables and Pearson chi-square
tests were used for categorical variables.
In order to determine trends in the use of r-PCI over
time, the study period was divided into quarters and the
rates of r-PCI were calculated for each quarter. Similarly,
the rates of r-PCI usage were also calculated in different
patient subgroups to demonstrate the differences in trend
over time. Subgroups considered were age 75 years versus
75 years, women versus men, and different PCI indications (stable angina, nonST-segment elevation acute coronary syndrome [NSTE ACS], and ST-segment elevation
myocardial infarction [STEMI]).
The unadjusted rates of the primary outcomes between
r-PCI and f-PCI were calculated in the overall population
as well as in the subgroups of age 75 versus 75 years,
women versus men, and stable angina versus NSTE ACS
versus STEMI. In examining the association between
r-PCI and outcomes, a multivariable logistic regression was
used to estimate the marginal effects of r-PCI. The generalized estimating equations method (12) was used to account for within-hospital clustering, as patients at the same
hospital are more likely to have similar responses relative to
patients in other hospitals (i.e., within-center correlation for
response). This method produces estimates similar to those
from ordinary logistic regression, but the estimated variances of the estimates are adjusted for the correlation of
outcomes within each hospital. Due to the low number of
bleeding events and unsuccessful PCI procedures in the
r-PCI group, we avoided overfitting the logistic regression
models by including ACC-NCDR mortality risk score as a
covariate in the models for procedure success and bleeding
complications (13). The ACC-NCDR risk score consists of
cardiogenic shock, age, salvage/urgent/emergent PCI, preprocedure intra-aortic balloon pump insertion, left ventricular ejection fraction, presentation with acute myocardial
infarction, diabetes mellitus, renal failure, chronic lung
disease, thrombolytic therapy, use of nonstent devices, and
lesion characteristics including the left main artery, proximal
left anterior descending disease, and Society for Cardiac
Angiography and Interventions lesion classification (c-index
0.89). Additional covariates included in the model for
procedure success are ACC/American Heart Association
lesion risk, bifurcation disease, chronic total occlusion, and
pre-procedure TIMI flow. Additional variables included in
the model for bleeding outcome are gender, body mass
index, glycoprotein IIb/IIIa inhibitor use, unfractionated

381

heparin use, direct thrombin inhibitor use, history of congestive heart failure, and peripheral vascular disease. The
effects of patient age (75 vs. 75 years), patient gender,
and PCI indication on the relationship between r-PCI and
the outcomes were assessed by including interaction terms
between arterial entry location (radial or femoral) and the
groups of interest in the models adjusted for NCDR risk
score. We repeated the analysis after excluding centers that
did not perform any r-PCI procedures during the study
period. A p value 0.05 was considered significant for all
tests. All statistical analyses were performed by the Duke
Clinical Research Institute using SAS software (version 9.0,
SAS Institute, Cary, North Carolina).
Results
Study population. Of the 725,549 procedures entered into the
NCDR during the study period, 593,094 PCI procedures
remained after applying the exclusion criteria. Of these, 7,804
(1.32%) procedures were performed via the radial artery approach. Figure 1 displays the prevalence of r-PCI across
hospitals; the vast majority of centers performed 10% of PCI
procedures via the radial artery approach. However, there were
7 centers in the database that performed 40% of PCI
procedures via the radial approach.
Table 1 displays the baseline characteristics of r-PCI
versus f-PCI procedures. r-PCI procedures were performed
in slightly younger patients and in patients with significantly
higher body mass index, and with a higher prevalence of
peripheral vascular disease compared with f-PCI. There was
a significantly lower prevalence of prior coronary artery
bypass graft surgery, prior renal failure, and NSTE ACS or
STEMI among r-PCI patients. In terms of procedure
characteristics, r-PCI procedures had longer fluoroscopy
times, but there was no significant difference between r-PCI
and f-PCI in terms of total volume of contrast used (median
100
90

88.78

80
70
60
50
40
30
20
3.79

10

1.32

1.16

1.32

2.15

0.33

0.83

0.33

4-5.99%

6-7.99%

8-9.99%

1019.99%

2029.99%

3039.99%

40%

0
0-1.99%

2-3.99%

% use of r-PCI
Figure 1. Proportion of PCI Cases Performed Via the Radial Artery
Proportion of percutaneous coronary intervention (PCI) cases performed via
the radial artery approach (r-PCI) across sites.

382

Rao et al.
Trends in Radial and Femoral Approaches to PCI

JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 1, NO. 4, 2008

AUGUST 2008:379 86

Table 1. Baseline Characteristics of r-PCI and f-PCI Patients and Procedures*

Overall (n 593,094)

r-PCI (n 7,804)

f-PCI (n 585,290)

p Value

65.00
(56.00, 74.00)

64.00
(56.00, 73.00)

65.00
(56.00, 74.00)

0.01

34.34

29.09

34.41

0.01

28.95
(25.66, 33.11)

29.71
(26.13, 34.88)

28.94
(25.64, 33.09)

0.01

Diabetes mellitus

33.99

33.21

34.00

Hypertension

78.58

79.48

78.57

0.05

Peripheral vascular disease

12.63

15.76

12.59

0.01
0.01

Characteristic
Demographics
Median age, yrs
(25th, 75th percentiles)
Female gender
Median BMI, kg/m2
(25th, 75th percentiles)
Medical comorbidities

Prior renal failure

0.14

5.45

4.16

5.46

Prior PCI

38.55

37.70

38.56

0.12

Prior CABG

20.68

10.43

20.82

0.01

Stable angina/atypical chest pain

41.46

47.26

41.38

NSTE ACS

54.46

49.65

54.53

4.08

3.09

Procedural characteristics
0.01

Procedure indication

STEMI

4.09

11.40
(7.10, 18.50)

13.50
(8.70, 21.50)

11.30
(7.00, 18.50)

0.01

Any glycoprotein IIb/IIa inhibitor

39.79

36.95

39.83

0.01

Unfractionated heparin

52.84

77.27

52.52

0.01

Low-molecular-weight heparin

16.40

15.70

16.41

0.09

Bivalirudin

39.27

13.76

39.62

0.01

431.00
(304.00, 585.00)

494.00
(291.50, 633.00)

431.00
(304.00, 585.00)

Fluoroscopy time, min

(25th, 75th percentiles)
Procedural anticoagulation

Hospital characteristics
Number of beds, median
(25th, 75th percentiles)
University hospital
Number of annual PCI cases, median
(25th, 75th percentiles)

8.62
955.54
(628.42, 1,645.00)

11.89
866.83
(472.21, 1,966.50)

8.58
955.54
(630.82, 1,645.00)

0.01
0.01
0.01

*Numbers shown are percentages unless otherwise noted.

BMI body mass index; CABG coronary artery bypass grafting; f-PCI femoral approach to percutaneous coronary intervention; NSTE ACS nonST-segment elevation acute coronary syndrome;
PCI percutaneous coronary intervention; r-PCI radial approach to percutaneous coronary intervention; STEMI ST-elevation myocardial infarction.

[25th, 75th percentiles] r-PCI 200 cc [140, 250] vs. f-PCI

200 cc [140, 260]). Unfractionated heparin was more
commonly used for r-PCI procedures, while bivalirudin and
glycoprotein IIb/IIIa inhibitors were more commonly used
for f-PCI procedures. r-PCI procedures were performed
more commonly at university hospitals.
Trends in r-PCI over time. Figures 2A to 2D display the
prevalence of r-PCI over time in the overall dataset as well as
in the key subgroups of age, gender, and PCI indication. The
use of r-PCI remained stable until the first quarter of 2007
when the proportion increased, although the sample size was
relatively smaller during the first quarter of 2007. This trend
was also present among the subgroups defined by age, gender,
and PCI indication; however, the use of r-PCI in patients age
75 years, women, and patients with ACS (both NSTE ACS
and STEMI) was lower than among patients 75 years, men,
and patients with stable angina.

Outcomes. Figure 3 displays the unadjusted rates of the

primary outcomes between r-PCI and f-PCI. Importantly,

there were only 15 r-PCI patients who developed a vascular
complication (0.19%). Table 2 shows the association between
r-PCI and the primary outcomes after multivariable adjustment. There was no significant association between the arterial
approach used and procedural success; however, there were
significantly lower adjusted odds for the occurrence of bleeding
complications with r-PCI. As stated in the preceding text,
there were too few vascular complications among r-PCI
patients to perform multivariable adjustment.
We repeated the analysis after excluding procedures reported by centers that did not perform any r-PCI. After
excluding these centers, 343,467 procedures remained, of
which 7,804 (2.27%) were performed via radial artery approach. Baseline patient and procedure characteristics of r-PCI
and f-PCI in this subset were similar to those seen in the

Rao et al.
Trends in Radial and Femoral Approaches to PCI

JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 1, NO. 4, 2008

AUGUST 2008:379 86

3.5
3

4
3.5
3

2.5

1.5
1

1.5

0.5

20
06
20
06
Q
tr
4
2
Q 006
tr
1
20
07

tr
2

tr
3

05

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20

20
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05

05
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tr
4

tr
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05
20

20

04
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tr
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20

tr
4

tr
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04

04

tr
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20

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tr
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20
04

(N
=2
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(N
=3
20
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Q
(N
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91
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(N
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=6
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tr
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61
05
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(6
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tr
4
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05
88
Q
(N
)
tr
1
=6
20
58
06
14
Q
(N
)
tr
2
=7
20
95
06
22
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(N
)
tr
3
=8
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23
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65
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(N
)
tr
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=7
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93
06
71
(N
)
Q
tr
=7
1
76
20
13
07
)
(N
=2
60
3)

0.5

Q
tr
1

Age < 75 yrs

Age 75 yrs

2.5

383

3.5

4
Males
Females

2.5

Stable angina
NSTE ACS

STEMI

1.5

0.5
0

20
05
2
Q 005
tr
4
2
Q 005
tr
1
2
Q 006
tr
2
2
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tr
3
2
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tr
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tr
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20
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tr
2

tr
4

tr
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20

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04
20

20

tr
3
Q

04
20

tr
2

tr
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05

04

20
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tr
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20
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tr
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20
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tr
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tr
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20
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tr
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20
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20
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2

tr
1

20

20

04
Q

tr
4

20
tr
3

04
20

tr
2
Q

tr
1

20

04

Figure 2. Trend in the Use of r-PCI Over Time in Key Subgroups

Trend in the use of the radial approach to percutaneous coronary intervention (r-PCI) over time in (A) the overall dataset; (B) patients age 75 and 75 years;
(C) men and women; (D) patients with stable angina, nonST-segment elevation acute coronary syndrome (NSTE ACS), and ST-segment elevation myocardial
infarction (STEMI).

overall study population; in addition, the adjusted outcomes

were nearly identical to those seen in the overall population
(data not shown).

100

95.53

94.68

90
r-PCI
f-PCI

Incidence (%)

80
70
60
50

Outcomes among key subgroups. Figures 4A to 4C display

the incidence of bleeding and vascular complications with

r-PCI and f-PCI in the key subgroups. The incidence of
both complications was lower for r-PCI among all patient
subgroups examined. Notably, there were no reported
bleeding or vascular complications among patients with
STEMI treated with r-PCI.
The interaction terms of age, gender, and PCI indication
were significant in the adjusted analysis of bleeding, such
that the protective effect of r-PCI on bleeding complications
Table 2. Unadjusted and Adjusted Association Between r-PCI and
Primary Outcomes (f-PCI as Reference)

40
30
20

Outcome

10
0.19

0
Procedure
success

0.70

Vascular
complication

0.79

1.83

Bleeding
complication

Unadjusted Odds Ratio

(95% CI)

Adjusted Odds Ratio

(95% CI)

Procedural success

1.09 (0.971.23)

1.02 (0.921.12)

Any bleeding complication

0.38 (0.260.54)

0.42 (0.310.56)

Procedural success model adjusted for American College of Cardiology-National Cardiovascular

Data Registry risk score (13), American College of Cardiology/American Heart Association lesion

Figure 3. Unadjusted Rates of the Primary Outcomes of r-PCI and f-PCI

Unadjusted rates of procedure success, vascular complications, and bleeding complications between the radial approach to percutaneous coronary
intervention (r-PCI) and the femoral approach to percutaneous coronary
intervention (f-PCI).

risk, bifurcation disease, chronic total occlusion, and pre-procedure Thrombolysis In Myocardial
Infarction flow grade. Any bleeding complication model adjusted for American College of
Cardiology-National Cardiovascular Data Registry risk score (13), gender (female as reference),
body mass index, glycoprotein IIb/IIIa inhibitor use, unfractionated heparin use, direct thrombin
inhibitor use, congestive heart failure, and peripheral vascular disease.
CI confidence interval; other abbreviations as in Table 1.

384

Rao et al.
Trends in Radial and Femoral Approaches to PCI

JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 1, NO. 4, 2008

AUGUST 2008:379 86

ysis of procedural success, demonstrating that r-PCI and

f-PCI had similar associations with procedural success
across the subgroups examined.

A
3.5

Bleeding
Complications
2.99

Discussion

2.5
2.05

Vascular
Complications

1.42

1.5

r-PCI
f-PCI

1.00

1
0.62

0.5

0.47

0.44
0.13

0
< 75 yrs

3.5

75 yrs

< 75 yrs

75 yrs

Bleeding
Complications

2.86

2.5

2
1.5

Vascular
Complications

1.22

1.10

r-PCI
f-PCI

1.06

This analysis of a national contemporary multicenter PCI

registry demonstrates several findings as they relate to the
radial artery approach to PCI in clinical practice. First,
although the proportion of PCI procedures performed via
the radial approach increased during the last quarter of the
time period studied, it was very uncommon overall, with
most centers performing 10% of cases via the radial artery.
Second, r-PCI is used less frequently among patients at risk
for PCI-related complications, such as the elderly patients,
women, and patients with ACS. Third, r-PCI is associated
with a significantly lower risk for bleeding and vascular
complications without sacrificing procedural success or involving more use of contrast agents. Finally, when r-PCI
was used in patients 75 years, women, and patients with
ACS, the rate of bleeding and vascular complications was
lower compared with that in f-PCI. These data support the
efficacy and safety of r-PCI in clinical practice and suggest
that wider application of the radial approach may enhance
the safety of coronary intervention.

0.67
0.52

0.5

0.31

Table 3. Effect of Patient Age, Patient Gender, and PCI Indication

on the Association of r-PCI With Procedural Success and
Bleeding Complications*

0.14

0
Males

Females

Males

Females

Category

Adjusted Odds Ratio

(95% CI)

Age 75 yrs

0.95 (0.821.12)

Age 75 yrs

1.06 (0.951.19)

Outcome

Bleeding
Complications

3.5

Procedural success

3.07

3
2.5
2

r-PCI
f-PCI

%
1.5
1

Vascular
Complications

1.29

0.76

0.67

0.5

0.19

0.72

0.21

Stable
angina

NSTE
ACS

STEMI

0.79

Stable
angina

NSTE
ACS

0.71 (0.471.06)

0.10

Age 75 yrs

0.31 (0.190.49)

0.01

Men

1.04 (0.921.17)

0.55

Women

1.02 (0.861.22)

0.80

Men

0.53 (0.380.75)

0.01

Women

0.38 (0.240.60)

0.01

Stable angina

1.09 (0.921.28)

0.33

NSTE ACS

0.99 (0.861.12)

0.82

STEMI

0.91 (0.571.46)

0.87

0.01

Procedural success

Figure 4. Unadjusted Rates of Bleeding and Vascular Complications of

r-PCI and f-PCI in Key Subgroups
Unadjusted rates of bleeding and vascular complications of r-PCI and f-PCI
in key subgroups of age (A), gender (B), and indication for percutaneous
coronary intervention (C). NSTE ACS nonST-segment elevation acute
coronary syndrome; STEMI ST-segment elevation myocardial infarction;
other abbreviations as in Figure 3.

0.32

Age 75 yrs

Any bleeding complication

STEMI

0.56
0.01

Procedural success

0.88

0.61

Any bleeding complication

2.07

p Value

0.81

0.70
0.01

Any bleeding complication

Stable angina

0.57 (0.390.82)

0.01

NSTE ACS

0.39 (0.270.58)

0.01

*Interaction p value shown in bold; There were no bleeding events among STEMI patients

was more pronounced among patients age 75 years,

women, and patients with NSTE ACS (Table 3). The
interaction terms were not significant in the adjusted anal-

treated with r-PCI; thus, the interaction could not be examined. Procedure success and Any
bleeding complication models adjusted for American College of Cardiology-National Cardiovascular Data Registry risk score (13).
Abbreviations as in Tables 1 and 2.

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Trends in Radial and Femoral Approaches to PCI

JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 1, NO. 4, 2008

AUGUST 2008:379 86

Randomized trials have previously shown an advantage of

r-PCI over f-PCI with respect to access site complications
(including bleeding), early ambulation, and costs (6 8).
Mann et al. (6) randomly assigned 142 patients with ACS
to PCI via the radial or femoral artery approach and
observed similar rates of PCI success with both approaches,
but noted significantly fewer access site complications with
the radial approach, which was associated with a 15%
decrease in hospital costs by reducing length of stay.
Similarly, Kiemeneij et al. (8) randomly assigned 900
patients undergoing PCI to either the femoral, brachial, or
radial artery approach and found that the incidence of
vascular complications was significantly lower among patients assigned to the radial approach; in fact, there were no
complications in the radial artery group, compared with
2.3% in the brachial artery group and 2.0% in the femoral
artery group (p 0.035). Agostoni et al. (14) performed a
meta-analysis of 12 studies, both randomized and observational, and found that the radial approach was associated
with a 71% to 85% decrease in the odds of entry site
complications. The aforementioned studies by Mann et al.
(6) and Kiemeneij et al. (8) were conducted at a single
center, and the studies included in the Agostoni et al. (14)
meta-analysis were also either single center or included
fewer than 7 sites. Our results confirm the outcomes seen in
these prior studies and extend them to contemporary clinical
practice by utilizing a database of over 700,000 procedures
from more than 600 hospitals. This reduction in PCIrelated complications may ultimately confer significant survival advantages in patients who are at high risk for vascular
complications after PCI (15,16).
Despite the potential safety advantage of r-PCI, our study
shows that the radial approach is very infrequently used in
clinical practice among the sites represented in the NCDR;
in particular, it is less frequently used among elderly
patients, women, and patients with ACS. Potential reasons
for this include the learning curve associated with this
technique, unwillingness to adopt a new approach on the
part of interventionalists, concerns over longer fluoroscopy
times, or a lack of a concerted effort on the part of industry
to encourage the radial approach through marketing of
devices specifically designed for that application. Goldberg
et al. (17) evaluated procedural success in an initial series of
27 patients undergoing PCI via the radial artery for an
operator inexperienced with r-PCI. They found that the
rate of successful PCI was 84%, with the most significant
limiting factor being spasm of the radial artery, which
occurred in 30% of cases. Current combinations of spasmolytic drugs injected into the radial artery during or immediately after sheath insertion virtually eliminate arterial
spasm and facilitate procedural success (18,19). While we
could not measure the number of failed attempts at radial
arterial access, our data do show that once radial access is

385

obtained, the rate of procedural success is statistically similar

to that seen with the femoral approach.
Some limitations to our study should be considered. First,
the present analysis is not a randomized trial, and, as such,
unmeasured confounders could be present. However, we
adjusted for a wide array of clinical and procedural variables
and accounted for site clustering effects in our analysis. In
addition, only a proportion of the collected data are audited;
therefore, as in any large registry, there is a small potential
for inaccurate data collection. Second, as mentioned in the
preceding text, the ACC-NCDR only has information on
successful arterial access and does not capture unsuccessful
attempts at vascular access. Therefore, the r-PCI procedures
in our analysis represent cases in which radial artery access
was obtained successfully. Moreover, only the first PCI in
each patient was considered, and reaccess of the radial artery
was not examined. Despite these limitations, our results
suggest that once vascular access is obtained in the radial
artery, the rate of procedural success is high and the rate of
bleeding or vascular complications is low. Third, we examined r-PCI volumes by site, not by operator; thus, highvolume r-PCI operators could account for our findings.
Finally, although the definition of vascular complications is
quite broad in the NCDR, it may still underestimate the
rate of these complications among r-PCI patients, because
occlusion of the radial artery may occur with a palpable
radial artery pulse due to collateral circulation in the hand.
In addition, the NCDR does collect data with granularity
sufficient to examine bleeding complications according to
various bleeding definitions.
Conclusions
Our examination of a large contemporary multicenter PCI
registry demonstrates that there is marked variation in the
use of r-PCI. Overall, it is infrequently used in clinical
practice, but it is associated with a rate of procedural success
similar to the femoral approach and with lower rates of
bleeding and vascular complications. These findings were
present even among patients at high risk for PCI-related
complications such as elderly patients, women, and patients
with ACS. These data, in the context of prior clinical trials,
suggest that wider adoption of r-PCI in clinical practice
may improve the safety of PCI.
Reprint requests and correspondence: Dr. Sunil V. Rao,
Durham VA Medical Center, 508 Fulton Street (111A), Durham,
North Carolina 27705. E-mail: sunil.rao@duke.edu.

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Key Words: percutaneous coronary intervention radial

artery outcomes.