Coronary Artery Disease
Radial Versus Femoral Access for the Treatment of Left Main Lesion in the Era of Second-Generation Drug-Eluting Stents

https://doi.org/10.1016/j.amjcard.2017.03.262Get rights and content

Transradial access (TRA) is often avoided in favor of the transfemoral access (TFA) during percutaneous coronary interventions of the unprotected left main coronary artery (ULM), due to technical and safety concerns. The aim of this study was to compare the performance of TRA and TFA in the treatment of ULM with second-generation drug-eluting stents. Consecutive patients who underwent percutaneous coronary intervention on ULM with second-generation drug-eluting stents were retrospectively enrolled in the multicenter Failure in Left Main Study With 2nd Generation Stents (FAILS 2) registry. Patients were stratified according to the arterial access. The choice between TRA and TFA was left to each operator's preferences. Bleedings during index hospitalization were the primary end point. Secondary end points were major adverse cardiovascular events (a composite of death, reinfarction, and target lesion revascularization), the single components of major adverse cardiovascular events at follow-up and stent thrombosis. Propensity score matching was executed to account for possible confounding. Overall, 1,247 patients were enrolled (23.2% [289] of female gender, mean age 70.2 ± 10.2 years). Diagnosis at presentation was stable angina in 603 (48.7%) cases, non–ST-segment elevation acute coronary syndrome in 465 (37.3%), ST-segment elevation myocardial infarction in 117 (9.5%). Mean follow-up was 726 ± 654 days. After propensity score with matching, 354 patients were included. The primary end point was significantly reduced in patients treated with TRA (2.0% vs 4.0%, p = 0.042), whereas no differences emerged pertaining the secondary end points, including target lesion revascularization and reinfarction. In conclusion, TRA may reduce in-hospital bleedings in patients undergoing percutaneous treatment of the ULM, without increasing the rate of adverse cardiovascular events at follow-up, and may therefore be safely used in the treatment of the ULM.

Section snippets

Methods

The Failure in Left Main Study With 2nd Generation Stents (FAILS 2) is a multicenter registry retrospectively enrolling patients who underwent percutaneous treatment of ULM with second-generation DES between July 2006 and March 2015.8 Five European centers were involved. All consecutive patients with indication to PCI of ULM stenosis were included, independently from clinical presentation. Patients with previous coronary artery bypass surgery, but no patent grafts supplying the left anterior

Results

Study population included 1,247 patients (23.2% [289] of female gender), with a mean age of 70.2 ± 10.2 years. Baseline features are reported in Table 1. Mean follow-up was 726 ± 654 days.

TRA was chosen in 250 patients (20.1%), and the prevalence of its use increased steadily during the course of the study, from 8.1% of the procedures performed in the period June 2006 to March 2010 to 38.7% in the period July 2013 to March 2015 (Supplementary Figure 1). The choice of arterial access according

Discussion

The main findings of the present study are:

  • (1)

    TRA may reduce in-hospital bleedings in patients undergoing percutaneous treatment of ULM, without increasing the rate of adverse cardiovascular events at follow-up.

  • (2)

    TRA can be safely chosen in the treatment of ULM with second-generation DES and could potentially provide some benefits through the reduction of the acute-phase bleedings.

TRA has been demonstrated to reduce mortality compared with TFA in patients undergoing PCI, mainly due to a reduction of

Acknowledgment

Authors' contributions: Drs. Gili and D'Ascenzo helped in conception and design of the study, data analysis, interpretation of data analysis, manuscript draft, and manuscript review; Drs. Di Summa, Cerrato, Chieffo, and Boccuzzi in study conception and design and data analysis; Drs. Conrotto, Montefusco, Ugo, Omedé, Kawamoto, Tomassini, and Pavani in interpretation of data analysis and manuscript critical review; Drs. Varbella, Garbo, D'Amico, Zoccai, Moretti, Escaned, Chieffo, and Gaita in

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