Transradial versus Transfemoral Approach in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome. A Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials

BACKGROUND: Transfemoral approach (TFA) remains the most common vascular access for percutaneous coronary intervention (PCI) in many countries. However, in the last years several randomized trials compared transradial approach (TRA) with TFA in patients with acute coronary syndrome (ACS), but only few studies were powered to estimate rare events. The aim of the current study was to clarify whether TRA is superior to TFA approach in patients with ACS undergoing percutaneous coronary intervention. A meta-analysis, meta-regression and trial sequential analysis of safety and efficacy of TRA in ACS setting was performed. METHODS AND RESULTS: Medline, the Cochrane Library, Scopus, scientific session abstracts and relevant websites were searched. Data concerning the study design, patient characteristics, risk of bias, and outcomes were extracted. The primary endpoint was death. Secondary endpoints were: major bleeding and vascular complications. Outcomes were assessed within 30 days. Eleven randomized trials involving 9,202 patients were included. Compared with TFA, TRA significantly reduced the risk of death (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.53-0.94; p = 0.016), but this finding was not confirmed in trial sequential analysis, indicating that sufficient evidence had not been yet reached. Furthermore, TRA compared with TFA reduced the risk of major bleeding (OR 0.60; 95% CI, 0.41-0.88; p = 0.008) and vascular complications (OR 0.35; 95% CI, 0.28-0.46; p<0.001); these findings were supported by trial sequential analyses. CONCLUSIONS: In patients with ACS undergoing PCI, a lower risk of death was observed with TRA. Nevertheless, the association between mortality and TRA in ACS setting should be interpreted with caution because it is based on insufficient evidence. However, because of the clinical relevance associated with major bleeding and vascular complications reduction, TRA should be recommended as first-choice vascular access in patients with ACS undergoing cardiac catheterization.