Abstract 14773: Risk-Treatment Paradox in the Selection of Transradial Access for Percutaneous Coronary Intervention: An Opportunity for Quality Improvement
Introduction: Access site complications contribute to morbidity and mortality during percutaneous coronary intervention (PCI). Transradial approach (TRA) significantly lowers the risk of complications compared to the transfemoral approach (TFA). We sought to 1) develop a prediction model for access site complications in patients undergoing TFA to PCI, and 2) assess whether the TRA was selectively used in patients at high risk for femoral complications.
Methods: We analyzed 17,509 patients who underwent PCI without intra-aortic balloon pump from 2008 to 2011 at 5 institutions in Massachusetts. Using backward selection with univariate prescreening (p < 0.2 for entry, p < 0.05 to stay), we developed a prediction model for access complications in the TFA population using pre-PCI variables. The model was internally validated via boostrap re-sampling.
Results: TRA was used in 17.8% of patients. In the entire cohort, 181 patients (1.0%) had access site complications. The final model had 10 significant predictors: age (p=0.002), female gender (p<0.001), elevated troponin (p<0.001), creatinine > 1 mg/dL (p=0.03), emergent PCI (p=0.01), prior PCI (p=0.001), hypertension (p=0.027), peripheral artery disease (p=0.004), and dialysis (p=0.003). The model showed moderate discrimination (c-statistic = 0.77) and was well-calibrated (Hosmer-Lemeshow p=0.63). Patients with higher predicted risk of complications via TFA were less likely to get TRA (p<0.001) (Figure). Similar results were seen in patients presenting with and without STEMI. Patients who underwent TRA were predicted to have 27 complications had they undergone TFA, but only experienced 4.
Conclusions: We generated and validated a model for access site complications for TFA PCI. Paradoxically, patients most likely to develop access site complications from TFA, and therefore benefit from TRA, were the least likely to receive TRA. This discrepancy is a potent opportunity for quality improvement in PCI.
- © 2012 by American Heart Association, Inc.