Percutaneous Coronary Intervention in Dialysis Patients: Insights from a Nationwide Registry Analysis

BACKGROUND: Trans-radial intervention (TRI) has become the standard of care for percutaneous coronary intervention (PCI). However, in patients on dialysis, trans-femoral intervention (TFI) remains predominant to preserve upper-limb vessels for arteriovenous fistula despite heightened hemorrhagic risk. This study aimed to compare TRI and TFI in dialysis patients undergoing PCI. METHODS: We used the National Cardiovascular Data Registry CathPCI Registry to compare patients on dialysis who underwent PCIs with TRI versus TFI from January 2018 to June 2025. An instrumental variable analysis with the institutional proportion of TRI use was performed to assess the risk of access-site bleeding and other peri-procedural outcomes. RESULTS: Among 137,702 dialysis patients who underwent PCI, 28.3% of patients underwent TRI (n=38,901), while 71.7% patients underwent TFI (n=98,801). TRI was associated with a lower risk of bleeding at the access site (adjusted risk difference [aRD]: -0.35%; 95% confidence interval [CI]: -0.56% to -0.15%). Overall bleeding (aRD: -1.38%; 95% CI: -1.89% to -0.87%), access-site hematoma (aRD: -0.86%; 95% CI: -1.13% to -0.60%), myocardial infarction (aRD: -0.21%; 95% CI: -0.39% to -0.03%), and mortality (aRD: -1.07%; 95% CI: -1.64% to -0.51%) were also less frequently observed in TRI. Conversely, TRI was associated with a higher risk of stroke (aRD: 0.23%; 95% CI: 0.001% to 0.45%), driven primarily by ischemic stroke. CONCLUSIONS: TRI was associated with a lower risk of bleeding events, but the effect size was modest. The higher observed stroke risk highlights a potential ischemic trade-off and warrants further study.