Compared with a transfemoral approach (TFA), using a transradial approach (TRA) for unprotected left main coronary artery (ULMCA) disease results in a comparable procedural success rate, a lower rate of vascular complications, similar fluoroscopy time, and shorter hospital stays. TRA should be considered as an alternative to TFA in performing percutaneous coronary intervention (PCI) for ULMCA diseases.

Ali A. Youssef, MD, Suez Canal University Hospital, Ismailia, Egypt, presented the results of a retrospective analysis of patients (mean age 67 years; mostly men) with LM stenosis ≥50% who were not eligible for coronary artery bypass graft (CABG) and underwent either TRA (n=116) or TFA (n=15) for ULMCA stenting. Patients were stratified for risk of death at 30 days using the EuroSCORE, with high risk being a score ≥6. Angiographic success was defined as TIMI 3 flow with residual diameter stenosis <30%. Procedural success was defined as angiographic success that was achieved without procedure-related death, myocardial infarction (MI), repeat PCI, or emergent CABG during hospitalization. Other study endpoints included vascular complications (eg, local hematoma, regional ischemic changes, peripheral artery occlusion, TIMI major and minor bleeds) and early (in-hospital and 6-month) outcomes (eg, postprocedural MI, stent thrombosis, pulmonary edema, stroke). With the exception of significantly higher rates of hypertension (p=0.043) and prior stroke in the TFA group (p=0.019), patients were well matched on demographics and clinical characteristics. Almost two-thirds of the patients in both groups were high-risk (mean EuroSCORE 7.3 ± 3.7 in the TRA group vs 8.7 ± 5.1 in the TFA group; p=NS).

There were no differences in procedural time, angiographic or procedural success, TIMI 3 flow rates, percent residual stenosis, or achievement of complete revascularization (Table 1). In general, smaller catheter sizes were used with the TRA (85.3% of procedures used a 6 French in the TRA approach vs only 20% of TFA procedures). Local vascular complications were significantly (p<0.001) more common among patients in whom a TFA was used (26.6%) compared with those in whom a TRA was used (1.7% of patients). Events that were significantly more common in the TFA group were hematoma/ecchymosis >5 cm (20% of patients vs 1.7% of TRA patients; p=0.001) and pseudoaneurysm and TIMI minor bleeding (both 6.7% vs 0%; p=0.005). There were no TIMI major bleeds in either group.

Unadjusted event rates between the two groups during hospitalization and at 6 months are shown in Tables 2 and 3. In-hospital cardiovascular (CV) events were significantly (p=0.003) more common among patients in the TFA group. Mortality was also significantly higher in the TFA group (13.3% of patients) compared with the TRA group (0.9%; p=0.002). There were no differences in mean duration of hospitalization (6.9 ± 13.3 days for TRA and 7.5 ± 9.1 days for TFA; p=NS) or outcomes at 6 months.

Limitations to this study include its modest size, the lack of randomization to TRA or TFA, and the assessment at a single center, where the majority of approaches that were reported was a TRA. While the data that were presented are promising, in that they suggest that TRA may be considered as an approach for ULMCA interventions, larger randomized trials will be necessary to ascertain differences in outcomes between these two approaches.