JACC: PCI preferencewill that be an arm or a leg?

When it comes to stenting, physicians are continuing to choose to gain entry to the circulatory system through an opening in the leg instead of the arm, even though the latter option appears to be safer and have fewer side effects, according to a study in the August issue of Journal of the American College of Cardiology: Cardiovascular Intervention.

"Bleeding complications are reduced by 70 percent when interventional cardiologists go in through a radial artery in the wrist," said lead author Sunil Rao, cardiologist at Duke University Medical Center in Durham, N.C. "But our research shows that only a tiny fraction of stenting procedures are done this way. The study suggests that maybe it's time to change the way we practice."

The researchers reviewed data from 593,094 cases of PCI in 606 hospitals across the U.S. included in the National Cardiovascular Data Registry from 2004 to 2007. They tracked the incidence of radial PCI (r-PCI) versus leg or femoral PCI (f-PCI) during the three-year period and calculated which patients were more likely to get which option.

The investigators found that the arm approach had gained favor over the four-year period, but still comprised only 1.3 percent of the total number of procedures. They also found that 40 percent of radial PCI was performed in only seven centers. Academic medical centers were more likely to be sites of higher r-PCI use than centers not affiliated with a college or university, according to Rao and colleagues.

The data further revealed that r-PCI was more likely to be chosen as an approach for younger patients, those with significantly higher body mass index and patients with a higher prevalence of peripheral vascular disease, the authors wrote.

“The findings are somewhat surprising, given that numerous studies have shown that r-PCI is similarly successful to f-PCI, and that r-PCI can significantly lower risk of bleeding, especially among women, patients younger than 75 and people undergoing PCI for acute coronary syndrome," Rao said.

He added that previous studies have also shown that r-PCI may cost less because it can mean shorter time in the hospital for some patients.

Rao and colleagues noted that r-PCI is the preferred option in Europe, and that slower acceptance of the technique in the U.S. may be due to: normal resistance to change; resistance to having to master a new learning curve; and a lack of industry effort to market new devices specially designed for r-PCI.

The National Cardiovascular Data Registry and the American College of Cardiology funded the study.