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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe RIVAL Trial showed that radial access for coronary angiography with possible percutaneous coronary intervention is not superior to femoral access. In secondary and exploratory analyses, the study observed that radial access was associated with a reduction in major vascular access site complications, was superior for the primary outcome when performed at high-volume radial centers, and was associated with better outcomes for patients with ST-segment elevation myocardial infarction.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECoronary Artery Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices Clinical Trials\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Radiology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EA large, randomized multicenter trial has shown that radial access for coronary angiography with possible percutaneous coronary intervention (PCI) is not superior to femoral access. In secondary and exploratory analyses, the study observed that radial access was associated with a reduction in major vascular access site complications, was superior for the primary outcome when performed at high-volume radial centers, and was associated with better outcomes for patients with ST-segment elevation myocardial infarction (STEMI). Sanjit S. Jolly, MD, McMaster University, Hamilton, Ontario, Canada, presented the findings of the study.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe Radial versus Femoral Access for Coronary Intervention (RIVAL; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01014273\u0026amp;atom=%2Fspmdc%2F11%2F3%2F16.atom\u0022\u003ENCT01014273\u003C\/a\u003E) trial was designed to provide randomized controlled trial data to test the hypothesis that radial access is superior to femoral access in patients with acute coronary syndrome (ACS) who are undergoing PCI. This hypothesis was generated by a meta-analysis that showed a significant reduction in bleeding events with radial access, with a trend toward fewer ischemic events, among patients with ACS [Jolly SS. \u003Cem\u003EAm Heart J\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe RIVAL trial first enrolled patients as part of the ACS trial CURRENT-OASIS 7 [CURRENT\u2013OASIS 7 Investigators. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010]. Patients were included in RIVAL if an invasive approach was planned and if the interventional cardiologist was willing to proceed with either radial or femoral access and had expertise for both (at least 50 radial procedures for coronary angiography or intervention within the previous year). The original sample size of 4000 was increased to 7000 by the RIVAL steering committee during the trial due to a lower-than-expected overall event rate for the primary outcome and because a sample size of 7000 would provide 80% power to detect a 25% relative risk reduction with a control event rate of 6% and a 30% relative risk reduction with a control event rate of 4% to 5%.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003ERIVAL enrolled 7021 patients at 158 hospitals in 32 countries. The patients were randomly assigned to radial access (n=3507) or femoral access (n=3514). The primary outcome was a composite of death, myocardial infarction (MI), stroke, or noncoronary artery bypass graft (non-CABG)-related major bleeding at 30 days. Secondary outcomes included death, MI, or stroke at 30 days; non-CABG-related major bleeding at 30 days; and major vascular access site complications.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EThere were no significant differences between the two groups with respect to either the primary or secondary outcomes that were related to death, MI, stroke, or non-CABG-related bleeding. The primary outcome occurred in 3.7% of the patients in the radial group and 4.0% of the patients in the femoral group (HR, 0.92; 95% CI, 0.72 to 1.17; p=0.50). There was, however, a difference in the rate of major vascular site complications, with fewer complications that were associated with radial access (1.4% vs 3.7%; HR, 0.37; 95% CI, 0.27 to 0.52; p\u0026lt;0.0001).\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EThe researchers compared the two approaches in six prespecified subgroups: age (\u0026lt;75 and \u226575 years), gender, body mass index, PCI volume by operator, radial access volume by center, and diagnosis at presentation (non-STEMI and STEMI). The results were similar in all subgroups with two exceptions: a significant difference was observed in favor of radial access when performed at centers with the highest volume of radial access procedures (HR, 0.49; 95% CI, 0.28 to 0.87; p=0.015) and in patients with STEMI (HR, 0.60; 95% CI, 0.38 to 0.94; p=0.026).\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EOverall, RIVAL showed no significant benefit for radial access compared with femoral access in patients who presented with ACS. Reasons for this neutral result may include inadequate power to detect a difference of the magnitude that was observed. In the associated manuscript, the authors state, \u201cRIVAL was underpowered to conclusively rule out moderate but important differences in the primary outcome. On the basis of the reported event rate of 4%, a sample of size of 17,000 patients would be needed to have 80% power to detect a 20% relative risk reduction in the primary outcome.\u201d Although the findings are neutral overall, clinicians may find the observations that radial access was associated with reduced rates of major vascular complications compared with femoral access and that the effectiveness of radial access appeared to be associated with expertise and volume to be helpful in clinical decision-making.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section ref-list\u0022 id=\u0022ref-list-1\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EFurther Reading\u003C\/h2\u003E\u003Col class=\u0022cit-list ref-use-labels\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022ref-label ref-label-empty\u0022\u003E\u003C\/span\u003E\n            \u003Cdiv class=\u0022cit ref-cit ref-journal no-rev-xref\u0022 id=\u0022cit-11.3.16.1\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EJolly\u003C\/span\u003E  \u003Cspan class=\u0022cit-name-given-names\u0022\u003ESS\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E \n               \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003ELancet\u003C\/abbr\u003E \n               \u003Cspan class=\u0022cit-pub-date\u0022\u003E2011\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/11\/3\/16.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzn361\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}