Abstract and Introduction
Abstract
Background Use of the transradial approach (TRA) in percutaneous coronary intervention (PCI) has increased in recent years. TRA has a lower mortality rate than the transfemoral approach (TFA) in patients with acute coronary syndrome. Comparative studies have systematically excluded patients with cardiogenic shock (CS).
Methods We performed a prospective, observational registry study of consecutive patients undergoing emergent revascularization between February 2007 and January 2012. An analysis of the clinical evolution of patients with CS during hospitalization was performed.
Results Of 1,400 emergency procedures, 122 had CS, of which 80 underwent PCI by TRA (65.6%) and 42 underwent PCI by TFA (34.3%). The main reason for choosing TFA was the absence of radial pulse (54.9%). Mortality (64.3% vs 32.5%, P = .001), serious access site complications (11.9% vs 2.5%, P = .03), access site complications requiring blood transfusion (7.1% vs 0%, P = .04), and major adverse cardiac events (death, infarction, stroke, serious bleeding, and postanoxic encephalopathy) (73.8% vs 43.8%, P = .001) were greater in patients treated by TFA. In the multivariate analysis, TRA was a predictor of mortality (odds ratio [OR] 0.39 [0.15–0.97]); other predictive factors were age ≥75 years (3.47 [1.35–8.92]), previous treatment with diuretics (3.67 [1.21–11.12]), and success of the procedure (0.07 [0.02–0.24]).
Conclusions Transradial approach for PCI is possible and safe in up to two-thirds of patients with CS. Absence of radial pulse was the main factor preventing use of TRA. In multivariate analysis, TRA was associated with a lower risk of mortality.
Introduction
The incidence of cardiogenic shock (CS) in patients with acute myocardial infarction varies between 5% and 15%, depending on the definition used. Despite advances in percutaneous coronary intervention (PCI), CS continues to be associated with an in-hospital mortality rate of approximately 50%. Results of the SHOCK study showed that emergent revascularization must be performed on patients with CS. Although the primary end point (decrease in mortality at 30 days by early revascularization) was not achieved in this study, there was a significant decrease in mortality that was maintained at 6 months, 12 months, and 6 years of follow-up. Several subsequent studies showed that early revascularization improves survival.
In 1989, Campeau reported on their experience performing coronary angiography using the transradial approach (TRA). In 1993, Kiemeneji and Laarman described their experience using this approach in PCI. Since then, use of TRA has expanded and is now a clear alternative to the classic transfemoral approach (TFA). In a population of patients with ST-segment elevation myocardial infarction (STEMI) undergoing PCI, a recent meta-analysis showed that TRA is associated with a significant decrease in mortality, major adverse cardiac events (MACEs), and serious access site complications compared with TFA. In previous studies comparing TRA and TFA in primary angioplasty, patients with CS were systematically excluded from analysis. Even centers with a long-standing tradition of using TRA in PCI omitted CS patients when reporting results of these procedures. Our center began using TRA in PCI in 2003; since then, this access route has been established as the approach of choice, used in >95% of PCI procedures performed over the last few years.
The objective of this study was to analyze PCI outcomes in a center performing a high volume of PCI using TRA in a cohort of consecutive patients with CS.