34 Do Centres that Usually Perform Percutaneous Coronary Intervention Trans-Radially have Inferior Outcomes when Operating Trans-Femorally?

Abstract

Background: Over the last decade trans-radial artery access has become more common than trans-femoral access for Percutaneous Coronary Intervention (PCI) in the United Kingdom. Despite studies highlighting the benefits of this transition in practice, concerns remain that the resulting drop in trans-femoral activity has caused centre proficiency with this approach to diminish, compromising the safety and efficacy of procedures where femoral access is necessary. Purpose: To evaluate the association of each centre's recent experience of femoral access with procedural outcomes in femoral procedures. Methods: This retrospective cohort study used procedures recorded in the British Cardiovascular Intervention Society (BCIS) PCI audit from 2007 to 2013 in England and Wales. Centres were split into one of three groups depending on the proportion of total procedures undertaken via the femoral artery in 2013, with patient and procedural characteristics for femoral procedures observed within these groups over time. “Recent femoral experience” was defined as the number of femoral procedures performed by the centre in the 12 months prior to the procedure date. The proportion of femoral procedures was also considered. The association of these measures with 30-day mortality, after risk-adjustment, were then studied using multiple logistic regression. Results: A total of 235,474 procedures were available for analysis. Unadjusted mortality in centres who were early-adopters of routine trans-radial access increased more rapidly than for centres who maintained high femoral activity, and this was driven by higher baseline risk. After case-mix adjustment recent femoral experience was found to have no effect on 30-day mortality (OR=0.99 per 0.1 increase in recent femoral proportion; CI: 0.96 to 1.01; p=0.220), with similar results when restricting to procedures with low clinical-complexity (OR=0.98 per 0.1 increase in recent femoral proportion; CI: 0.95 to 1.01; p=0.245). Conclusions: Poorer outcomes in femoral procedures at high radial centres are driven by the propensity of these centres to utilise femoral access in the highest risk patients. Once differences in case-mix are adjusted for, femoral outcomes are similar between high and low radial proportion centres with no evidence to suggest that increasing unfamiliarity with the femoral technique is detrimental. The outcome gains achieved by the national adoption of radial access is not attenuated by decreased femoral experience, and centres should be encouraged to continue to adopt radial as the default access site for PCI wherever possible.