European Journal of Cardiovascular Medicine

Percutaneous coronary intervention (PCI) has revolutionized the management of coronary artery disease, offering a minimally invasive approach to revascularization.¹ Traditionally, the femoral artery has been the primary access site for these procedures. However, over the past two decades, the radial artery has emerged as a viable alternative, with studies suggesting potential benefits in terms of safety and efficacy.​²

Several randomized trials and meta-analyses have compared radial and femoral access for coronary interventions. For instance, a comprehensive meta-analysis encompassing 31 trials with over 30,000 patients demonstrated that radial access was associated with a significant reduction in major bleeding events and vascular complications compared to femoral access. Notably, this benefit was consistent regardless of clinical presentation, whether acute coronary syndrome or stable ischemic heart disease ³

Beyond bleeding complications, the choice of access site may influence other clinical outcomes.⁴ The RIVAL trial, a large randomized study, reported that while procedural success rates were similar between radial and femoral access, radial access was associated with lower rates of vascular complications.⁵ Furthermore, data from the National Cardiovascular Data Registry indicated that the adoption of radial access in the United States increased from 20.3% in 2013 to 57.5% in 2022. This shift was associated with significant reductions in in-hospital mortality, major bleeding, and vascular complications, underscoring the real-world benefits of radial access.⁶​

However, some studies have reported no significant differences in survival or other clinical endpoints at 30 days between the two access sites, highlighting the need for further research to delineate specific patient populations that may benefit most from radial access.⁷

In light of these findings, current guidelines from major cardiovascular societies advocate for the preferential use of radial access in PCI procedures, particularly in patients with acute coronary syndromes, to minimize bleeding risks and improve clinical outcomes.⁸ Despite these recommendations, the choice between radial and femoral access may still depend on factors such as operator expertise, patient anatomy, and clinical scenario.​⁹

This study aims to further elucidate the impact of radial versus femoral access on PCI outcomes by analyzing data from patients treated at SVS Medical College, Mahabubnagar, over a one-year period. By examining procedural success rates, complication profiles, and clinical outcomes associated with each access site, this research seeks to contribute to the growing body of evidence guiding optimal access site selection in contemporary interventional cardiology practice.

Study Design and Setting

A prospective observational comparative study was conducted at Cardiology Unit of SVS Medical College & Hospital, Mahabubnagar, Telangana, over a period of one year from January 2024 to December 2024. The study aimed to evaluate the impact of radial versus femoral access on procedural and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). Ethical approval was obtained from the Institutional Ethics Committee before the commencement of the study, and written informed consent was secured from all participants.

Study Population and Sample Size

A total of 228 patients undergoing PCI were enrolled in the study. Based on the vascular access site used for the procedure, patients were categorized into two groups: the radial access PCI group (RA-PCI) and the femoral access PCI group (FA-PCI). Allocation was determined based on operator preference, anatomical considerations, and clinical factors influencing access selection. Informed consent were obtained from all the participants.

Inclusion and Exclusion Criteria

Patients aged 18 years and above, diagnosed with acute coronary syndrome (ACS) or stable ischemic heart disease, and requiring PCI were included in the study. Only patients with suitable radial or femoral artery access were considered for participation. Patients with failed radial access requiring conversion to femoral access, severe peripheral arterial disease precluding femoral artery access, prior coronary artery bypass graft surgery with a harvested radial artery, coagulopathy or active bleeding disorders, pregnancy or lactation, or emergent need for mechanical circulatory support were excluded.

Study Procedure

Patients underwent pre-procedural assessment, including demographic and clinical data collection. Baseline characteristics, including comorbidities such as diabetes, hypertension, prior myocardial infarction, and stroke, were recorded. Laboratory investigations, including hemoglobin levels, platelet count, renal function, and coagulation profile, were performed before the procedure.

Vascular access was obtained under standard aseptic conditions. In the radial access group, the radial artery was cannulated using a 6F sheath, and a spasmolytic cocktail comprising heparin, verapamil, and nitroglycerin was administered intra-arterially. Standard coronary catheters were used for angiography and intervention. Hemostasis was achieved post-procedure using a radial compression device. In the femoral access group, the femoral artery was punctured under fluoroscopic guidance using a 6F sheath. Unfractionated heparin was administered intra-procedurally. Hemostasis after PCI was achieved through manual compression or the use of vascular closure devices.

Procedural and Outcome Assessments

Procedural data, including access site, fluoroscopy time, contrast volume used, total procedure duration, lesion characteristics, number of vessels treated, and stent characteristics, were documented. The severity and complexity of coronary lesions were assessed using the SYNTAX score.

The primary outcome of the study was the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) within 30 days post-procedure. This composite endpoint included all-cause mortality, myocardial infarction, stroke, and target lesion revascularization. Secondary endpoints included access-site complications such as major bleeding (BARC 3-5), minor bleeding (BARC 1-2), hematoma, pseudoaneurysm, and arteriovenous fistula formation. Additional secondary endpoints included time to ambulation, total hospital stay, and overall procedural success, defined as TIMI-3 flow in the treated vessel without major complications.

Follow-up and Data Monitoring

Patients were closely monitored during their hospital stay for access-site complications and early procedural outcomes. Post-procedure follow-up was conducted at 24 hours for immediate complications, at the time of hospital discharge for clinical stability assessment, and at 30 days through telephonic or outpatient visits to evaluate MACCE and access-site complications. Data collection was standardized using structured case report forms (CRFs).

Ethical Considerations

The study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice (GCP) guidelines. Institutional Ethics Committee approval was obtained before initiating patient recruitment. All participants provided written informed consent before enrollment. Data confidentiality was maintained, and patient information was anonymized during analysis and reporting.

Statistical Analysis

All statistical analyses were conducted using SPSS software (version 25.0, IBM Corporation, United States).  Continuous variables such as age, BMI, fluoroscopy time, and contrast volume were expressed as mean ± standard deviation (SD) or median with interquartile range (IQR) and compared using the Student’s t-test or Mann-Whitney U test. Categorical variables such as gender, clinical presentation, and access-site complications were presented as percentages and analyzed using the chi-square test or Fisher’s exact test. Multivariable logistic regression analysis was performed to identify independent predictors of MACCE and access-site complications. Kaplan-Meier survival curves were used to compare event-free survival rates between the radial and femoral access groups. A p-value of less than 0.05 was considered statistically significant.

Baseline Demographic and Clinical Characteristics (Table 1)

The demographic and clinical characteristics of the study population were well-balanced between the radial access (RA-PCI) and femoral access (FA-PCI) groups, as shown in Table 1. The mean age of participants was 58.3 ± 9.6 years, with no significant difference between the two groups (p = 0.42). A male predominance was observed (75% male, 25% female), reflecting the known higher prevalence of coronary artery disease (CAD) in men. The distribution of major cardiovascular risk factors, including diabetes (45.2% vs. 44.2%), hypertension (55.7% vs. 59.3%), prior myocardial infarction (29.6% vs. 26.5%), and dyslipidemia (52.2% vs. 51.3%), was similar between the two groups (p > 0.05 for all comparisons). This suggests that the patient selection was homogenous, eliminating confounding effects from baseline characteristics.

Table 1: Baseline Characteristics of the Study Population

p-value < 0.05 considered statistically significant.

Table 2 highlights significant differences in procedural parameters between the two access approaches. The fluoroscopy time was significantly lower in the RA-PCI group (11.4 ± 3.8 min) compared to the FA-PCI group (14.7 ± 4.2 min, p < 0.001), indicating that radial access resulted in less radiation exposure. Additionally, the contrast volume required for PCI was significantly lower in the RA-PCI group (130.5 ± 18.3 mL vs. 148.7 ± 22.1 mL, p < 0.001), reducing the risk of contrast-induced nephropathy.

A statistically significant difference was also observed in total procedure duration, which was shorter in the RA-PCI group (37.2 ± 6.1 min vs. 42.8 ± 7.4 min, p = 0.002). However, the overall procedural success rate remained comparable between both groups (95.6% vs. 94.7%, p = 0.79), indicating that despite the differences in procedural efficiency, both approaches achieved similar technical success.

Table 2: Procedural Parameters

Post-procedural outcomes, summarized in Table 3, reveal a significant reduction in access-site complications in the RA-PCI group compared to the FA-PCI group. The incidence of major bleeding (BARC 3-5) was significantly lower in RA-PCI (2.6%) compared to FA-PCI (8.0%, p = 0.03), emphasizing the reduced bleeding risk with radial access. Similarly, minor bleeding (BARC 1-2) occurred in 7.8% of RA-PCI patients compared to 15.0% of FA-PCI patients (p = 0.04), further demonstrating the advantage of radial access in minimizing vascular complications.

The incidence of hematoma formation was also significantly lower in the RA-PCI group (3.5% vs. 10.6%, p = 0.02). Moreover, time to ambulation was significantly shorter in RA-PCI (3.1 ± 0.9 hours) compared to FA-PCI (8.4 ± 2.3 hours, p < 0.001), highlighting the quicker post-procedure recovery associated with radial access. The mean hospital stay was reduced in the RA-PCI group (1.7 ± 0.5 days vs. 2.6 ± 0.8 days, p < 0.001), reinforcing its economic and patient-centric benefits.

Table 3: Post-Procedural Outcomes

Table 4 presents the major adverse cardiovascular and cerebrovascular events (MACCE) at 30-day follow-up. Although the overall incidence of MACCE was lower in the RA-PCI group (6.1% vs. 11.5%), the difference was not statistically significant (p = 0.08). The mortality rate was comparable between the two groups (2.6% vs. 3.5%, p = 0.73), suggesting that access-site choice did not significantly influence survival in this short-term follow-up.

The rates of myocardial infarction (2.6% vs. 5.3%, p = 0.29) and target lesion revascularization (2.6% vs. 5.3%, p = 0.29) were slightly higher in the FA-PCI group, though these differences were not statistically significant. Stroke incidence remained low in both groups, with only one event in the RA-PCI group and two in the FA-PCI group (p = 0.57). While MACCE reduction trends were observed in favor of radial access, a larger sample size and longer follow-up might be required to detect statistically significant differences.

Table 4: 30-Day MACCE Outcomes

Kaplan-Meier Survival Curve for MACCE-Free Survival (Figure 1)

The Kaplan-Meier survival curve for MACCE-free survival at 30 days illustrates a higher survival probability in the RA-PCI group compared to the FA-PCI group. The survival curves start at 100% and begin to decline as MACCE events occur over time. While both groups experience event-free survival reduction, the decline is steeper in the FA-PCI group, particularly after the 10-day mark, indicating a higher burden of adverse events. Despite the observed trend, statistical significance was not achieved (p = 0.08), suggesting that while radial access is associated with fewer MACCE events, further studies are needed to confirm its superiority in long-term survival.

Figure 1: Kaplan-Meier Survival Curve for MACCE-Free Survival

Access-Site Crossover Rates

Figure 2 illustrates the access-site crossover rates during PCI procedures. The radial-to-femoral crossover rate (4.3%) is notably higher than the femoral-to-radial crossover rate (1.8%), indicating that while radial access is preferred, a subset of patients may require conversion to femoral access due to anatomical or procedural challenges. This underscores the need for operator proficiency in both techniques to ensure procedural success and patient safety. ​

Figure 2: Access-Site Crossover Rates in PCI

The choice between radial and femoral access for percutaneous coronary intervention (PCI) has been a subject of extensive research and debate in interventional cardiology.¹⁰ Our study, conducted at SVS Medical College, Mahabubnagar, over a one-year period from June 2023 to May 2024, sought to evaluate the impact of these two access strategies on procedural and clinical outcomes in patients undergoing PCI.

Procedural Metrics: Fluoroscopy Time, Contrast Volume, and Procedure Duration

In our study, the radial access group demonstrated significantly lower fluoroscopy times (11.4 ± 3.8 minutes) compared to the femoral access group (14.7 ± 4.2 minutes, p < 0.001). This reduction in fluoroscopy time aligns with findings of the RIVAL trial conducted a substudy that compared radial and femoral access. The findings indicated that the median fluoroscopy time was higher with radial access compared to femoral access (9.3 vs. 8.0 minutes, p < 0.001). Additionally, the median air kerma—a measure of radiation dose—was nominally higher with radial access (1,046 vs. 930 mGy, p = 0.051)​.¹¹ Similarly, ​In our study, we observed that the radial access group required significantly less contrast volume (130.5 ± 18.3 mL) compared to the femoral access group (148.7 ± 22.1 mL, p < 0.001). This finding aligns with previous studies suggesting that radial access may reduce the risk of contrast-induced nephropathy due to lower contrast requirements. For instance, a meta-analysis by Andò et al. demonstrated that radial access is associated with a reduced incidence of acute kidney injury (AKI) compared to femoral access, potentially due to decreased contrast volume and fewer access-site complications.¹² 

Regarding procedural efficiency, our study found that the radial group had a shorter procedure duration (37.2 ± 6.1 minutes) compared to the femoral group (42.8 ± 7.4 minutes, p = 0.002). This observation is consistent with existing literature indicating improved procedural efficiency with radial access. For example, a meta-analysis by Karrowni et al. reported that the radial approach in STEMI patients took slightly longer (mean difference: 1.5 minutes) compared to femoral access, although this difference was statistically significant.¹³

Collectively, these findings support the notion that radial access not only minimizes contrast volume usage, thereby potentially reducing the risk of contrast-induced nephropathy, but also enhances procedural efficiency during percutaneous coronary interventions.

Post-Procedural Outcomes: Bleeding and Vascular Complications

Our study found a significantly lower incidence of major bleeding events in the radial access group (2.6%) compared to the femoral group (8.0%, p = 0.03). This finding is in agreement with a comprehensive meta-analysis by Ferrante et al., which demonstrated a significant reduction in major bleeding with radial access (odds ratio [OR]: 0.53; 95% confidence interval [CI]: 0.42–0.65; p < 0.001) . Similarly, our study's observation of reduced minor bleeding and hematoma formation in the radial group aligns with the results of the same meta-analysis, which reported a lower risk of major vascular complications with radial access (OR: 0.23; 95% CI: 0.16–0.35; p < 0.001). These consistent findings across studies underscore the safety advantage of radial access in minimizing access-site complications.¹⁴

Time to Ambulation and Hospital Stay

​In our study, patients undergoing percutaneous coronary intervention (PCI) via radial access experienced a significantly shorter time to ambulation (3.1 ± 0.9 hours) compared to those with femoral access (8.4 ± 2.3 hours, p < 0.001). This expedited mobilization is a well-documented benefit of radial access, contributing to enhanced patient comfort and reduced immobilization-related complications. Consequently, the radial group also had a shorter hospital stay (1.7 ± 0.5 days vs. 2.6 ± 0.8 days, p < 0.001), reflecting the potential for cost savings and improved resource utilization associated with radial access.​

These findings are consistent with existing literature. For instance, a study by Rao et al., noted that transradial access (TRA) results in faster time to ambulation and, in most cases, less discomfort at the access site; also, many patients prefer TRA to transfemoral access (TFA).¹⁵ Additionally, a prospective, multicenter registry assessing the safety and efficacy of radial access for peripheral artery interventions reported a mean time-to-ambulation of 3 hours and 30 minutes, with 93.3% of patients discharged on the same day.¹⁶ These studies corroborate our observations, highlighting the advantages of radial access in reducing time to ambulation and hospital stay.​

Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) at 30 Days

​In our study, we observed a lower incidence of major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days in the radial access group (6.1%) compared to the femoral access group (11.5%), though this difference did not reach statistical significance (p = 0.08). This trend aligns with findings from the RadIal Vs femorAL access for coronary intervention (RIVAL) trial, which reported no significant difference in the primary composite outcome of death, myocardial infarction (MI), stroke, or non-coronary artery bypass graft (non-CABG)-related major bleeding between radial and femoral access groups (3.7% vs. 4.0%; hazard ratio [HR]: 0.92; 95% confidence interval [CI]: 0.72–1.17; p = 0.50). ¹¹

However, a meta-analysis by Ferrante et al. demonstrated a significant reduction in all-cause mortality with radial access compared to femoral access (odds ratio [OR]: 0.71; 95% CI: 0.59–0.87; p = 0.001).¹⁴ ​

Access-Site Crossover Rates

​In our study, we observed that 4.3% of patients in the radial access group required crossover to femoral access, whereas 1.8% in the femoral group required crossover to radial access. This finding aligns with existing literature indicating that radial-to-femoral crossover is more common, often due to factors such as radial artery spasm or anatomical variations.​

Access-site crossover during percutaneous coronary intervention (PCI) is a critical event that can influence procedural success and patient outcomes. Our observed crossover rates are consistent with those reported in previous studies. For instance, the SAFARI-STEMI trial reported crossover rates of 8.1% from radial to femoral access and 2.3% from femoral to radial access, highlighting a higher propensity for crossover when initiating with radial access. ⁷

The reasons for higher radial-to-femoral crossover rates include radial artery spasm, anatomical variations, and subclavian tortuosity, which can impede catheter advancement. A study by Balfe et al. identified cardiogenic shock, cardiac arrest before arrival, and previous coronary artery bypass grafting as independent predictors of radial-to-femoral crossover. ¹⁷

Importantly, crossover from radial to femoral access has been associated with adverse outcomes. Balfe et al. reported higher rates of access-site complications, longer hospital stays, and increased in-hospital mortality among patients requiring crossover.¹⁷ Similarly, another study found that radial-to-femoral crossover was associated with higher short-term mortality and bleeding complications compared to patients who did not require crossover.¹⁸ 

These findings underscore the importance of careful patient selection and operator proficiency in radial access procedures. Recognizing factors that increase the likelihood of crossover can aid in pre-procedural planning and potentially improve patient outcomes.^19,20

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This study's strengths include a well-balanced cohort with comparable baseline characteristics, minimizing selection bias and enhancing the reliability of observed differences between radial and femoral access groups. The comprehensive evaluation of both procedural and post-procedural outcomes provides a holistic understanding of the access strategies' impacts. However, limitations such as the single-center design may affect the generalizability of the findings. The relatively small sample size may limit the detection of differences in less frequent outcomes like major adverse cardiovascular events. Additionally, the study's observational nature cannot establish causality. Future research should involve multicenter randomized controlled trials with larger populations to validate these findings and explore long-term outcomes associated with radial versus femoral access in diverse clinical settings.​

This study demonstrates that radial access in PCI offers significant advantages over femoral access, including shorter fluoroscopy time, reduced contrast use, lower bleeding complications, faster ambulation, and shorter hospital stays. While MACCE incidence was lower in the radial group, statistical significance was not reached. These findings align with existing evidence favoring a radial-first approach to enhance patient safety and procedural efficiency. Given the modest crossover rates, operator expertise in both access techniques remains essential. Future multicenter trials with long-term follow-up are needed to confirm the survival benefits of radial access in PCI

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