Author + information
- Rahman Shah1,
- Inyong Hwang Hwang2,
- Mannu Nayyar3,
- Ellis Christian4,
- Kodangudi Ramanathan5 and
- Abdul Rashid6
Several recent meta-analyses of randomized controlled trials (RCTs) demonstrate that trans-radial access (TRA) decreases mortality and MACE rates in patients with acute coronary syndrome (ACS) undergoing PCI. In those RCTs, however, the MACE and mortality rates were unexpectedly high when trans-femoral access (TFA) was used by redial experts (REs), leading to concern that the significant difference favoring TRA could have been a result of an increased incidence of adverse events in the TFA arms. Therefore, we performed a network meta-analysis comparing adverse events across four groups (TFA and TRA by both REs and non-radial experts [NREs]).
Relevant RCTs were included in a Bayesian network meta-analysis using mixed treatment comparison models to compare outcomes across the four groups.
We included data from 13 RCTs involving 12,735 patients. Mortality and MACE rates were decreased in TRA if either operator(REs or NREs,) was compared with TFA by REs only, not by NREs (figure). Furthermore, TFA by NREs was associated with decreased MACE and mortality rates compared with TFA by REs (Figure).
In ACS patients undergoing PCI, TRA irrespective of operator experience is associated with decrease MACE rate and improved survival only when compared with TFA by REs, not by NREs. This suggests that MACE and survival benefits of TRA in these RCTs and meta-analyses may be influenced by an increased incidence of adverse events in the TFA arms, rather than a beneficial effect of TRA. This issue needs further investigation before making significant changes to American guidelines.
CORONARY: Acute Coronary Syndromes