Procedural Volume and Outcomes With Radial or Femoral Access for Coronary Angiography and Intervention
Abstract
To evaluate the relationship between procedural volume and outcomes with radial and femoral approach. BACKGROUND: RIVAL was a randomized trial of radial vs. femoral access for coronary angiography/ intervention (N=7021) which overall did not show a difference in primary outcome of death, MI, stroke or non-CABG major bleeding.
METHODS: In pre-specified subgroup analyses, the hazard ratios for the primary outcome were compared i) among centres divided by tertiles and ii) among individual operators. A multivariable cox proportional hazards model was used to determine the independent effect of centre and operator volumes after adjusting for other variables.
RESULTS: In high volume radial centres, the primary outcome was reduced with radial vs. femoral access (hazard ratio (HR) 0.49; 95%CI 0.28-0.87) but not in intermediate (HR 1.23; 95%CI 0.88-1.72) or low volume centres (HR 0.83; 95%CI 0.52-1.31); interaction p=0.021. High volume centres enrolled a higher proportion of STEMI.
After adjustment for STEMI, the benefit of radial persisted at high volume radial centers. There was no difference in the primary outcome between radial and femoral access by operator volume: high volume operators (HR 0.79; 95%CI 0.48-1.28), intermediate (HR 0.87; 95%CI 0.60-1.27) and low (HR 1.10; 95%CI0.74-1.65); interaction p=0.536.
However, in a multivariable model, overall centre volume and radial centre volume were independently associated with the primary outcome but not femoral centre volume (overall PCI volume HR 0.92; 95%CI 0.88-0.96, radial volume HR 0.88; 95%CI0.80-0.97 and femoral volume HR 1.00; 95%CI 0.94-1.07, p=0.98). CONCLUSIONS: Procedural volume and expertise are important, particularly for radial PCI.