Evaluation of three Percutaneous Arterial Approaches for Coronary Angiography: Randomized trial comparing femoral, brachial and radial access sites

pp 477-484

Abstract

Femoral approach has demonstrated to be easy and safe to perform a coronary angiography. Few hours of bed rest, physical activity restriction and high demand of medical and nursing facilities, remain as its main drawbacks. With the aim to evaluate if percutaneous brachial or radial approaches were able to overcome these limitations, without increasing complications or operative difficulties, we conducted a prospective randomized study. Between July 1994 and June 1995, 429 consecutive patients referred to coronary angiography were randomized to percutaneous femoral (F) (141 patients), brachial (B) (150 patients) or radial (R) (138 patients) approach. Baseline clinical characteristics were similar in the three groups. Primary end points were 1) time required for the procedure (total laboratory time, arterial time, fluoroscopy time and time to ambulating and discharge), 2) hospitalization dueto the selected approach and 3) pain attributable to the approach. A combination of major clinical events (dead, AMI, stroke, TIA, major bleeding and persistent limb ischemia) was selected as secondary end point. Major hematoma was also analyzed.All the variables were assessed during in-hospital stay and at 5 to 7 days follow-up (6.2 ±1.5). Time is expressed in minutes. In groups F. B and R, 7 (4.9%) 14 (9.3%) and 32 (23,1%) patients, respectively, wereunable to complete the study with the selected ap-proach. Laboratory time was significantly less (p<.05) in F compared with B and R (48 ±14; 56 ±17; and 56 ± 19, respectively). Similar results were obtained with fluoroscopy time (7 ± 5; 8.5 ± 8; 8.4 ± 7, for F, B and R groups, respectively) and arterial times (23 ± 9; 28 ± 12; 32 ± 15, respectively). Additionally, time elapsed before patients were able to ambulate was 251 ± 78; 21 ± 13 and 17 ± 7, for patients in F, B and R groups, respectively. In-hospital time was 276 ± 78; 73 ± 24; 60 ± 16 for F, B and R approaches, respectively (p < 0.05). All patients in R group were discharged the same day of the study(p <.05 R vs F). Pain was more frequent in R patients (8.7%) (p <.05). Limb ischemia was significantly higher in B (2.5%) compared to F and R (p <.05). No differences were observed in major complications or large hematoma.

Conclusions

1) All three approaches are safe and well tolerated. 2) Upper limb approaches (B and R) are good alternatives requiring less time before ambulation and discharge with potential impact on costs. 3) R and B approaches were linked to longer procedures and higher radiation exposure. 4) Limb ischemia was significantly higher in B. 5) Upper limb approaches(R and B) require change to an alternative pathway more frequently than the femoral approach.