Radial versus femoral access for coronary angiography and percutaneous coronary interventions in critically ill patients

BACKGROUND: Evidence is lacking to appraise whether radial access should be preferred to femoral access for coronary angiography (CAG) in critically ill patients. METHODS: Patients admitted to the medical intensive care unit (ICU) of a university hospital over a 5-year period and requiring CAG immediately before or during the ICU stay were retrospectively included. The average treatment effect of the arterial route used for CAG was assessed through a win-ratio methodology with propensity score (PS)-based inverse probability of treatment weighting (IPTW). The primary endpoint was a hierarchical composite outcome of (i) all-cause death, (ii) resuscitated cardiac arrest, (iii) stroke, (iv) myocardial infarction, (v) acute limb ischemia and/or need for vascular surgery on CAG access site and (vi) Bleeding Academic Research Consortium (BARC) type 3 major bleeding, all assessed at day 28. The relationship between access site and the likelihood of all-cause death at day 28 was investigated with a Cox proportional hazard model stratified on the occurrence of cardiac arrest before CAG and adjusted through PS-based IPTW. RESULTS: Among the 235 included patients (116 with femoral access and 119 with radial access), 145 (61.7%) were admitted following cardiac arrest and 116 (49.4%) presented with cardiogenic shock at the time of CAG. The primary composite endpoint occurred in 63.4% of patients with femoral access and 47.7% of patients with radial access in IPT-weighted populations (absolute risk difference 15.6%, 95% confidence interval [CI] 1.4% to 29.8%, P = 0.03; win ratio for femoral versus radial access 0.62, 95% CI 0.40 to 0.98, P = 0.04). Access site complications were more frequent in patients with femoral access while major bleedings were similarly observed in both groups. Femoral access was not associated with day-28 mortality (adjusted hazard ratio 1.43, 95% CI 0.90 to 2.26, P = 0.13). Percutaneous coronary revascularisation and implantation of veno-arterial extra-corporeal membrane oxygenation, when required, were not hastened with femoral access. CONCLUSION: In this study, the use of a femoral rather than radial approach for CAG in critically ill patients was associated with a higher incidence of access site complications but did not correlate with the hazard of major bleeding or all-cause death at day 28.