Does radial vs. femoral access for revascularization in ST-segment elevation myocardial infarction (STEMI) improve patients’ long-term outcomes?

Abstract

Background: Femoral access (FA) and radial access (RA) are both acceptable vascular approaches to provide primary percutaneous coronary intervention (PCI) in the setting of ST-segment elevation myocardial infarction (STEMI). Although short-term outcomes associated with RA supports its usage due to the lower bleeding rate, it is less clear if there is a long-term difference in outcomes with FA. Objectives: To assess and compare long term clinical outcomes such as all-cause mortality, major adverse cardiovascular events (MACE), bleeding, reinfarction and stroke rates between RA and FA in designations of patients with STEMI undergoing PCI. Methods: A systematic search of MEDLINE, Embase, and Cochrane CENTRAL databases was conducted in accordance with PRISMA 2020 guidelines. Studies were included if they reported outcomes at 30 days and beyond comparing RA and FA in STEMI patients undergoing PCI. Data extraction followed a pre-specified template. Risk of bias was assessed using the Cochrane RoB 2 tool for randomized controlled trials and the Newcastle–Ottawa Scale for cohort studies. A meta-analysis of eligible studies was performed using the inverse-variance random-effects model in Review Manager (RevMan 5.4). Quantitative synthesis was conducted for long-term all-cause mortality; MACE and major bleeding outcomes were summarised descriptively using bar charts due to heterogeneity in definitions and reporting. Results: Nine studies were included: two randomized controlled trials and seven observational cohort studies. Of these, eight provided long-term follow-up data (≥6 months). Pooled analysis demonstrated that RA was associated with a statistically significant reduction in long-term all-cause mortality compared to FA (RR 0.59, 95% CI 0.38–0.91, p = 0.02), with substantial heterogeneity (I² = 93%). MACE rates were generally lower in the RA group, and bleeding or vascular complications were consistently less frequent with RA. Subgroup analyses demonstrated favourable outcomes with RA in elderly patients, women, and those at high bleeding risk. Conclusion: Radial access has shown long-term clinical benefits over femoral access with STEMI patients receiving PCI, with particular benefits in reducing mortality, MACE and bleeding complications in the longer term. This clinically important benefits are even more pronounced in the high-risk subgroups and is in accordance with the current recommendations in the guidelines that RA should be the default access strategy. Future randomized trials are required to validate this important benefit, and to assess patient-reported and cost-effectiveness outcomes.