背景:在需要经皮冠状动脉介入治疗(PCI)的患者中,使用经桡动脉入路(TRA)优于经股动脉入路(TFA)是基于证据表明TRA与较少的出血和较少的血管并发症相关,缩短住院时间,提高生活质量,以及对死亡率的潜在有益影响。我们有限的研究数据比较了接受PCI的房颤(AF)患者的两种途径,这些患者的出血风险特别增加。而房颤本身与血栓栓塞风险增加相关。
方法:使用RIVA-PCI注册表中的数据,包括接受PCI的AF患者,我们分析了一个高出血风险(HBR)队列.这些患者主要使用口服抗凝剂(OAC)治疗房颤,PCI通过桡动脉或股骨入路进行。检查终点为院内出血(BARC2-5),大脑事件(TIA,出血性或缺血性中风)和冠状动脉事件(支架血栓形成和心肌梗塞)。
结果:在1636例患者中,854(52.2%)接受TFA,782人(47.8%)通过TRA接受了手术,包括9例肱动脉穿刺患者。平均年龄为75.5岁。群体在年龄方面相似,性别分布,AF类型,心血管病史,危险因素,和合并症,除了先前的旁路手术发生率较高,心力衰竭,高脂血症,TFA组肾小球滤过率(GFR)<60ml/min的慢性肾病(CKD)。在PCI时,抗血栓治疗和联合治疗没有临床相关差异。然而,放电时,经桡动脉PCI患者三联疗法的发生率较高,而经股骨手术后双重治疗是首选。非ST段抬高型心肌梗死(NSTEMI)和不稳定型心绞痛(UAP)病例更频繁地选择径向通路(NSTEMI26.6%vs.17.0%,p<0.0001;UAP21.5%vs.14.5%,p<0.001),而股骨入路更常见于择期PCI(60.3%与44.1%,p<0.0001)。对于ST段抬高型心肌梗死(STEMI)没有观察到差异。两组的脑事件发生率相似(TFA0.2%vs.TRA0.3%,p=0.93),但TFA组出血发生率较高(BARC2-5)(4.2%vs.1.5%,p<0.01),主要由BARC3出血引起(1.5%vs.0.4%,p<0.05)。支架内血栓形成和心肌梗死无显著差异(TFA0.2%vs.TRA0.3%,p=0.93;TFA0.4%与TRA0.1%,p=0.36)。
结论:在因急性或慢性冠状动脉综合征而接受PCI的HBR房颤患者中,使用TRA可能与住院出血减少有关,与股骨入路相比,不会增加栓塞或缺血事件的风险。需要进一步的研究来证实这些初步发现。
BACKGROUND: The preference for using transradial access (TRA) over transfemoral access (TFA) in patients requiring percutaneous coronary intervention (PCI) is based on evidence suggesting that TRA is associated with less bleeding and fewer vascular complications, shorter hospital stays, improved quality of life, and a potential beneficial effect on mortality. We have limited
study data comparing the two access routes in a patient population with atrial fibrillation (AF) undergoing PCI, who have a particular increased risk of bleeding, while AF itself is associated with an increased risk of thromboembolism.
METHODS: Using data from the RIVA-PCI registry, which includes patients with AF undergoing PCI, we analyzed a high-bleeding-risk (HBR) cohort. These patients were predominantly on oral anticoagulants (OAC) for AF, and the PCI was performed via radial or femoral access. Endpoints examined were in-hospital bleeding (BARC 2-5), cerebral events (TIA, hemorrhagic or ischemic stroke) and coronary events (stent thrombosis and myocardial infarction).
RESULTS: Out of 1636 patients, 854 (52.2%) underwent TFA, while 782 (47.8%) underwent the procedure via TRA, including nine patients with brachial artery puncture. The mean age was 75.5 years. Groups were similar in terms of age, sex distribution, AF type, cardiovascular history, risk factors, and comorbidities, except for a higher incidence of previous bypass surgeries, heart failure, hyperlipidemia, and chronic kidney disease (CKD) with a glomerular filtration rate (GFR) < 60 ml/min in the TFA group. No clinically relevant differences in antithrombotic therapy and combinations were present at the time of PCI. However, upon discharge, transradial PCI patients had a higher rate of triple therapy, while dual therapy was preferred after transfemoral procedures. Radial access was more frequently chosen for non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP) cases (NSTEMI 26.6% vs. 17.0%, p < 0.0001; UAP 21.5% vs. 14.5%, p < 0.001), while femoral access was more common for elective PCI (60.3% vs. 44.1%, p < 0.0001). No differences were observed for ST-segment elevation myocardial infarction (STEMI). Both groups had similar rates of cerebral events (TFA 0.2% vs. TRA 0.3%, p = 0.93), but the TFA group had a higher incidence of bleeding (BARC 2-5) (4.2% vs. 1.5%, p < 0.01), mainly driven by BARC 3 bleeding (1.5% vs. 0.4%, p < 0.05). No significant differences were found for stent thrombosis and myocardial infarction (TFA 0.2% vs. TRA 0.3%, p = 0.93; TFA 0.4% vs. TRA 0.1%, p = 0.36).
CONCLUSIONS: In HBR patients with AF undergoing PCI for acute or chronic coronary syndrome, the use of TRA might be associated with a decrease in in-hospital bleeding, while not increasing the risk of embolic or ischemic events compared to femoral access. Further studies are required to confirm these preliminary findings.