Comprehensive meta-analysis of radial vs femoral approach in primary angioplasty for STEMI

INTRODUCTION: Primary angioplasty has improved survival as compared to thrormbolysis. However, bleeding complications still represent the Achille's heel, mainly related to access site. Although the radial approach is getting larger consensus for elective percutaneous procedures, its safety and advantages in the setting of ST-segment elevation (STEMI) is controversial. Therefore, the aim of the current study was to perform a comprehensive meta-analysis of randomized and non randomized trials comparing radial vs transfemoral approach in primary angioplasty for STEMI. METHODS: The literature was scanned by formal searches of electronic databases (MEDLINE, Pubmed) from January 1990 to October 2012. No language restrictions were enforced. RESULTS: A total of 27 trials were finally included, with 29,194 patients (4685 enrolled in 11 randomized trials and 24,509 in 15 non randomized trials). A total of 10,052 patients underwent radial approach and 19,142 patients underwent femoral approach. A total of 2499 patients (8.6%) had died at follow-up. Radial approach was associated with a significant reduction in short-term mortality (5.2% vs 10.3%, OR [95% CI]=0.55 [0.40, 0.76], p<0.001, p het=0.97) (primary endpoint). Significant benefits were observed in both randomized (2.7% vs 4.7%, OR [95% CI]=0.55 [0.40, 0.76], p<0.001, p het=0.97) and observational studies (5.9% vs 11.1%, OR [95% CI]=0.48 [0.43, 0.54, p<0.001, p het=0.44]). Major bleeding complications were observed in a total of 808 patients (2.8%). Radial approach was associated with a significant reduction in major bleeding complications as compared to femoral approach (1.9% vs 4.7%, OR [95% CI]=0.38 [0.31, 0.47], p<0.0001, p het=0.17), similarly in both randomized (2.7% vs 5%, OR [95% CI]=0.51 [0.37, 0.70], p<0.001, p het=0.87) and observational studies (1.4% vs 4.6%, OR [95% CI]=0.32 [0.25, 0.42], p<0.0001, p het=0.32). Both benefits in death and major bleeding complications were not related to baseline risk profile. CONCLUSIONS: This meta-analysis of randomized and non-randomized trials showed that among STEMI patients undergoing primary angioplasty the radial approach is associated with a consistent reduction in mortality and major bleeding complications and. Therefore, routine use of radial approach should be strongly encouraged in primary angioplasty.