If the radial artery is the new standard of care in primary percutaneous coronary intervention, why is most intervention done by the femoral approach?

When Dr Mason Sones made the first major advance in interventional cardiology over 50 years ago with the advent of ‘selective coronary angiography’, 1 it is unlikely that he or others could have imagined its future pivotal role in the current revascularisation era, or perhaps the era itself! Then, selective coronary angiography quickly became a widespread and indispensible tool in the diagnosis of symptomatic obstructive coronary artery disease, and it was not long before alternatives to coronary artery bypass surgery emerged. Dotter and Judkins2 first introduced the concept of ‘recanalisation of arterio-sclerotic obstructions’ with the use of an intraluminal catheter, and Andreas Gruntzig took one giant step further in 1974 when he developed double lumen catheters with expansive qualities and demonstrated their utilisation in the dilatation of arterial obstruction in animal models. In Zurich in 1977 his first ischaemic patient underwent coronary reperfusion by the use of percutaneous transluminal coronary angioplasty.3 ‘Dr Andreas Gruntzig and his colleagues are to be congratulated… [He] provides evidence that… balloon angioplasty can effectively dilate highly stenotic coronary vessels and provide immediate improvement in coronary perfusion.’4 Urgent reperfusion for acute myocardial infarction (MI) is now commonplace with primary percutaneous coronary intervention (PPCI) being the treatment of choice in ST-segment elevation MI5. PPCI reduces mortality and decreases the rate of stroke and re-infarction; timing is important in this reduction.6 As well as a reduction in reperfusion time, we strive to achieve procedural success without complications. In percutaneous coronary intervention (PCI), but PPCI in particular, bleeding is a major complication as it can limit our ability to administer antithrombotic agents. Bleeding is an independent risk factor, increasing mortality and …