Radial versus femoral artery access in patients undergoing PCI for left main coronary artery disease: analysis from the EXCEL trial

EuroIntervention 2018;14:1104-1111 published online August 2018. DOI: 10.4244/EIJ-D-18-00711

Shmuel Chen
Shmuel Chen1, MD, PhD; Björn Redfors1, MD, PhD; Yangbo Liu1, MS; Ori Ben-Yehuda1,2, MD; Marie-Claude Morice3, MD; Martin B. Leon1,2, MD; David E. Kandzari4, MD; Roxana Mehran1,5, MD; Nicholas J. Lembo1,2, MD; Adrian P. Banning6, MD; Béla Merkely7, MD, PhD, DSc; Arie Pieter Kappetein8, MD, PhD; Joseph F. Sabik 3rd9, MD; Patrick W. Serruys10, MD, PhD; Gregg W. Stone1,2*, MD
1. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; 2. NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA; 3. Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Paris, France; 4. Piedmont Heart Institute, Atlanta, GA, USA; 5. The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 6. John Radcliffe Hospital, Oxford, United Kingdom; 7. Heart and Vascular Center, Semmelweis University, Budapest, Hungary; 8. Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands; 9. Department of Surgery, UH Cleveland Medical Center, Cleveland, OH, USA; 10. Imperial College of Science, Technology and Medicine, London, United Kingdom

Aims: We sought to compare clinical outcomes and procedural characteristics with transradial access (TRA) versus transfemoral access (TFA) in patients who were treated with PCI for left main (LM) coronary artery disease.

Methods and results: The EXCEL trial was a prospective, international, open-label, multicentre trial that randomised 1,905 patients with LM disease and SYNTAX scores ≤32 to PCI with everolimus-eluting stents versus coronary artery bypass grafting. The present analysis cohort consisted of 931 patients undergoing PCI with TRA or TFA, but not both. The primary endpoint was a composite of death, myocardial infarction (MI), or stroke at three years. Multivariable Cox proportional hazards regression was used to adjust for differences in baseline covariates. PCI in EXCEL was performed exclusively with TRA in 248 (26.6%) patients and with TFA in 683 (73.4%) patients. TRA patients were younger and less likely to have hypertension and chronic kidney disease. The mean number of vessels and lesions treated was higher in TFA patients, although the SYNTAX score was similar in both groups. Patients undergoing TRA and TFA had similar 30-day rates of TIMI major or minor bleeding (2.4% versus 3.8%, respectively, p=0.30). At three years, TRA and TFA patients had similar rates of the primary endpoint (15.7% versus 14.8%, adjusted HR 1.11, 95% CI: 0.73-1.69, p=0.64), as well as the individual rates of death, MI, stroke, ischaemia-driven revascularisation and stent thrombosis.

Conclusions: In the EXCEL trial, PCI of LM disease with TRA was associated with comparable early and late clinical outcomes to TFA.

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