Meta-analysis of stroke after transradial versus transfemoral artery catheterization
Introduction
Stroke after diagnostic cardiac catheterization or percutaneous coronary intervention (PCI) is a rare but devastating complication associated with significant morbidity and increased mortality [1]. Older age, female sex, prior stroke, hypertension, diabetes, chronic kidney disease, and low left ventricular ejection fraction are clinical predictors of an increased risk of stroke after PCI [1], [2], [3], [4]. Procedural factors associated with an increased risk of periprocedural stroke include undergoing PCI for acute coronary syndrome (ACS), urgent intra-aortic balloon pump placement, PCI of bypass grafts, and utilization of larger caliber catheters [1], [2], [4], [5], [6]. Concerns about a possible increased risk of stroke with transradial (TR) compared to transfemoral (TF) catheterization have emerged due to anatomic considerations, increased frequency of catheter exchanges, and longer procedure times associated with TR procedures. A recent trial comparing TR vs. TF catheterization in patients with severe aortic stenosis found numerically higher, but not statistically different, rates of cerebral infarcts detected by diffusion weighted magnetic resonance imaging (DW-MRI) in the TR arm (17.5% vs. 11.7%, p = 0.31) [7]. The last meta-analysis to address this issue, published in 2009, found no difference in the rates of stroke between TR vs. TF access among 2535 patients, but was significantly underpowered due to low event rates [8]. Since then, several randomized trials reporting stroke rates after TR vs. TF catheterization have been published, the largest of which demonstrated a numerically increased, but not statistically different, rate of stroke between TR and TF catheterization (0.6% vs. 0.4%, p = 0.30) [9]. Thus, we performed a meta-analysis to determine if there is a difference in stroke risk after TR vs. TF catheterization.
Section snippets
Search strategy
We performed a comprehensive search of the Pubmed, SCOPUS, and Cochrane Library (“Cochrane Database of Systematic Reviews” and the “Cochrane Central Register of Controlled Trials”) databases in March 2013. We performed keyword searches of the American Heart Association and American College of Cardiology websites, clinicaltrials.gov, and Google Scholar. Finally we considered published review articles, editorials, and internet-based sources of information (http://www.theheart.org) to identify
Statistical analysis
Data were combined to estimate the pooled risk difference (RD) and respective confidence intervals (CI) for TR vs. TF catheterization. The RD method was used to allow inclusion of zero event studies since stroke is a rare complication after cardiac catheterization. Heterogeneity among studies was evaluated with the Cochrane Q (p ≤ 0.1 was considered significant) and I2 statistics (25%, 50%, and 75% correlate with low, moderate, and high heterogeneity, respectively) for each outcome [12]. Begg's
Results
A total of 13 randomized trials enrolling 11,273 patients were included for analysis (Fig. 1). The majority of patients, 8987 (79.7%), were enrolled in ACS trials, with 1966 (21.9%) of those having STEACS (Table 1). Specific radial expertise was required in 8 out of 13 studies, which enrolled 9604 (85.2%) patients. The mean age of patients ranged from 58 to 83 years, and the majority were male (8008, 71.0%). Very few patients (270, 2.4%) had a history of prior coronary artery bypass grafting
Discussion
Over the last five years in particular, the use of TR catheterization has increased dramatically in the United States [17], [18]. Given this trend, it is important to continue to examine its safety profile as more data on safety and outcomes accrue. This is especially true in the case of rare adverse events, such as periprocedural stroke, which individual studies are often underpowered to detect. Prior studies comparing stroke risk in TR vs. TF catheterization have had mixed results, with some
Study limitations
A few key limitations of our study are noteworthy. First, despite aggregating data from over 11,000 patients, we had limited power to detect differences in stroke rates between TR and TF catheterization due to low overall event rates. Second, since most of the patients in the study did not have a history of prior CABG, the results may not be generalizable to the post-CABG population. This is important as patients with prior CABG require longer catheterization time, and more frequent catheter
Conclusions
Stroke after both TR and TF catheterization is a rare event. The results of our large meta-analysis suggest that compared to TF, TR catheterization is not associated with a significantly increased risk of stroke.
Conflict of interest disclosures
Dr. Patel: none.
Dr. Brayton: Supported by Grant Number HS000028 from the NIH; the contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the AHRQ.
Dr. Kumbhani: Honoraria: American College of Cardiology, Somahlutions.
Dr. Banerjee: Speakers' Bureau for St. Jude Medical Center, Medtronic Corp., and Johnson & Johnson; research grant from Boston Scientific.
Dr. Brilakis: consulting fees/Speaker honoraria from St Jude Medical,
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2022, IJC Heart and VasculatureCitation Excerpt :Our findings are similar to meta-analyses which showed no difference in the stroke rates between TR-PCI and TF-. PCI.[29,30] Furthermore, our study also showed non-significant lower odds of MI and cardiogenic shock in both groups.
Meta-Analysis of Transradial Versus Transfemoral Access for Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease
2021, American Journal of CardiologyCitation Excerpt :In our analysis there was no difference in terms of post-PCI stroke when compared between TR and TF access groups. Findings are consistent with the results of two previous meta-analysis of stroke after TR vs TF approach, although they were not specific for CKD patients.30,31 The similar risk of stroke and MI suggest that the higher risk of mortality is probably driven largely by the incidence of major bleeding in these patients.
In-Hospital acute ischemic stroke following ST-elevation myocardial infarction
2020, IJC Heart and VasculatureCitation Excerpt :Studies evaluating the incidence of stroke following myocardial infarction have reported different results, depending on the study population and design. Post PCI studies reported a slight increase in the incidence of ischemic stroke following myocardial infarction [5,13,30–32]. This is because PCI can slightly increases immediate post-procedure risk due to procedure complexity and possible manipulation of arterial atherosclerosis plaques [33,34].
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2017, JACC: Cardiovascular Interventions
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This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.