Transradial Versus Transfemoral Access for Bifurcation Percutaneous Coronary Intervention Using Second-Generation Drug-Eluting Stent

- ¹Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea.
- ²Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
- ³Department of Internal Medicine and Cardiovascular Centre, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
- ⁴Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea.
- ⁵Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Centre, Keimyung University College of Medicine, Daegu, Korea.
- ⁶Division of Cardiology, Department of Internal Medicine, Gachon University Gil Hospital, Gachon University College of Medicine, Incheon, Korea.
- ⁷Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.
- ⁸Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
- ⁹Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea.
- ¹⁰Division of Cardiology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea.
- ¹¹Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea.
- ¹²Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea.
- ¹³Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
- ¹⁴Division of Cardiology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea.
- ¹⁵Division of Cardiology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea.
- ¹⁶Division of Cardiology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.
- ¹⁷Division of Cardiology, Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea.
- ¹⁸Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea.
- ¹⁹Division of Cardiology, Department of Internal Medicine, St. Paul’s Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea.
- ²⁰Division of Cardiology, Department of Internal Medicine, Ajou University Hospital, Ajou University College of Medicine, Suwon, Korea.
- ²¹Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University College of Medicine, Gwangju, Korea.
- ²²Division of Cardiology, Department of Internal Medicine, Bucheon Sejong Hospital, Bucheon, Korea.
Address for Correspondence: Young Jin Youn, MD, PhD. Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Republic of Korea. Email: younyj@yonsei.ac.kr

Received August 03, 2023; Accepted January 23, 2024.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

The benefits of transradial access (TRA) over transfemoral access (TFA) for bifurcation percutaneous coronary intervention (PCI) are uncertain because of the limited availability of device selection. This study aimed to compare the procedural differences and the in-hospital and long-term outcomes of TRA and TFA for bifurcation PCI using second-generation drug-eluting stents (DESs).

Methods

Based on data from the Coronary Bifurcation Stenting Registry III, a retrospective registry of 2,648 patients undergoing bifurcation PCI with second-generation DES from 21 centers in South Korea, patients were categorized into the TRA group (n = 1,507) or the TFA group (n = 1,141). After propensity score matching (PSM), procedural differences, in-hospital outcomes, and device-oriented composite outcomes (DOCOs; a composite of cardiac death, target vessel-related myocardial infarction, and target lesion revascularization) were compared between the two groups (772 matched patients each group).

Results

Despite well-balanced baseline clinical and lesion characteristics after PSM, the use of the two-stent strategy (14.2% vs. 23.7%, P = 0.001) and the incidence of in-hospital adverse outcomes, primarily driven by access site complications (2.2% vs. 4.4%, P = 0.015), were significantly lower in the TRA group than in the TFA group. At the 5-year follow-up, the incidence of DOCOs was similar between the groups (6.3% vs. 7.1%, P = 0.639).

Conclusion

The findings suggested that TRA may be safer than TFA for bifurcation PCI using second-generation DESs. Despite differences in treatment strategy, TRA was associated with similar long-term clinical outcomes as those of TFA. Therefore, TRA might be the preferred access for bifurcation PCI using second-generation DES.

Trial Registration

ClinicalTrials.gov Identifier: NCT03068494

Graphical Abstract

Keywords

Transradial Approach; Bifurcation; Percutaneous Coronary Intervention; Drug-Eluting Stent

INTRODUCTION

Several randomized controlled trials have demonstrated that transradial access (TRA), compared to transfemoral access (TFA), offers similar procedural success rates while reducing vascular complications and mortality, particularly in patients with acute coronary syndrome.1, 2, 3 Current guidelines recommend TRA over TFA for patients with acute coronary syndrome and endorse TRA for patients with stable ischemic heart disease.4, 5

Recent technological advances in percutaneous coronary intervention (PCI) devices have made TRA the default route for treating complex coronary artery diseases. However, several operators advocate TFA over TRA during complex PCIs, likely because of the greater backup support with a large-bore guiding catheter and the availability of larger devices. Furthermore, no clear evidence or guidelines exist regarding the clinical benefits of TRA over TFA for complex PCI, such as bifurcation PCI, which accounts for approximately 15% of all PCI cases.6, 7 TRA is a feasible alternative, even for left main (LM) bifurcation treatment, in previous Coronary Bifurcation Stenting (COBIS) registries.8, 9 However, these registries involved first-generation drug-eluting stents (DESs). This study compared the procedural differences and in-hospital and long-term outcomes of TRA and TFA for bifurcation PCI using second-generation DESs.

METHODS

Study population

The COBIS III Registry, a multicenter, observational, real-world registry, includes 2,648 patients treated for bifurcation lesions using second-generation DESs between January 2010 and December 2014 at 21 PCI centers in South Korea. Patients were categorized into two groups based on the vascular access: TRA, 1,507 (56.9%) patients; TFA, 1,141 (43.1%) patients.

The major inclusion criteria were any bifurcation lesions treated solely with second-generation DESs; a main vessel diameter ≥ 2.5 mm; and a side branch diameter ≥ 2.0 mm, confirmed with core laboratory quantitative coronary angiography analysis. The major exclusion criteria were cardiogenic shock, cardiac arrest with successful resuscitation during hospitalization, protected LM disease, and severe left ventricular dysfunction (i.e., ejection fraction < 30%). The COBIS III Registry has been previously described.10

Procedural details

PCI procedures were performed using current standard guidelines and conventional techniques. All patients received a loading dose of aspirin (300 mg) and P2Y12 inhibitors (clopidogrel [300–600 mg], prasugrel [60 mg], or ticagrelor 180 mg]) at least 12 hours before PCI.4, 5 The vascular access route was selected by the attending physicians. Stenting techniques, including one- or two-stent strategies, final kissing balloon (FKB), proximal optimization technique (POT), or re-POT, and the DES were selected at the operators’ discretion. Intravascular ultrasound-guided intervention was recommended to obtain optimal stent expansion and apposition. The type, dose, and duration of dual antiplatelet therapy and cardiovascular medications were decided by the physician.

Data collection and quantitative coronary angiography analysis

A web-based reporting system collected data on the patients’ demographics, medications, laboratory findings, and angiographic and procedure details. Follow-up outcomes were collected from medical records or telephone interviews in cases of follow-up loss. An angiographic core laboratory (Heart Vascular Stroke Institute in Samsung Medical Center, Seoul, Korea) quantitatively analyzed baseline and procedural coronary angiograms using an automated edge-detection system (Centricity CA 1000; GE Healthcare, Waukesha, WI, USA).10 Bifurcation lesions were divided into three segments; proximal main vessel, distal main vessel, and side branch. Those with Medina Classifications11 of 1.1.1, 1.0.1, and 0.1.1 were considered true bifurcations.

Study endpoints

The primary endpoint was the incidence of device-oriented composite outcome (DOCO), defined as the composite of cardiac death, target vessel-related myocardial infarction (MI), and target lesion revascularization. The secondary endpoints included the individual components of the DOCO, patient-oriented composite outcome (i.e., a composite of death from any cause, any MI, and any revascularization), and target vessel revascularization. In-hospital outcomes were evaluated based on periprocedural complications, which included access site complications, periprocedural MI, emergent repeat procedures, cardiogenic shock, and acute heart failure. All clinical events were verified by an independent clinical event adjudicating committee composed of interventional cardiology experts not involved in patient enrolment, as previously described.10

Statistical analysis

Data are presented as number (%) or mean ± standard deviation. Continuous variables were compared using Student’s t-tests. Categorical variables were compared using χ² or Fisher’s exact tests. The cumulative events of clinical outcomes were assessed using Kaplan–Meier estimates and compared with log-rank tests. All clinical endpoints were analyzed until the date of an endpoint event, loss to follow-up, or up to 5 years after the index procedure.

Propensity scores were estimated using multivariate logistic regression analyses on all covariates listed in Tables 1 and 2. Nearest-neighbor matching with a caliper of 0.005 was used and considered satisfactory when the standardized mean differences were < 10% (Supplementary Fig. 1). The propensity scores yielded a C-statistic of 0.714, which indicated a good ability to differentiate between both groups. In subgroup analysis, adjusted hazard rates were calculated by means of multivariate Cox regression with clinical and lesion characteristics among propensity scores-matched populations.

Table 1
Baseline characteristics

Click for larger image
Click for full table
Download as Excel file

Table 2
Lesion characteristics

Click for larger image
Click for full table
Download as Excel file

Statistical analyses were conducted using SPSS version 26.0 (IBM Corp., Armonk, NY, USA) and R Statistical Software version 4.2.2 (R Foundation for Statistical Computing, Vienna, Austria). P values < 0.05 was considered statistically significant.

Ethics statement

The Institutional Review Board approved this study (Wonju Severance Christian Hospital IRB, CR316133). The requirement for patient-informed consent was waived owing to the retrospective nature of the study.

RESULTS

Baseline characteristics

In the total study population, patients in the TRA group were more likely to be male than those in the TFA group, and less likely to have a history of cardiovascular risk factors such as hypertension, insulin-dependent diabetes, dyslipidemia, chronic kidney disease, and previous cerebrovascular accident (Table 1). In addition, patients with ST-segment elevation MI were less likely to be treated via TRA. After conducting propensity score matching (PSM), no statistical differences existed between the two groups with respect to baseline clinical variables, clinical presentation, and medications at discharge.

Lesion characteristics

In the total study population, the prevalence of complex lesions was lower in the TRA group than in the TFA group (Table 2). Specifically, the TRA group had a lower incidence of multivessel disease, LM bifurcation lesions, in-stent restenosis lesions, chronic total occlusion, and thrombotic lesions. However, after PSM, all lesion characteristics were similar between the two groups.

Procedural characteristics and in-hospital adverse outcomes

In the total study population, patients in the TRA were more likely to be treated with the one-stent strategy, whereas patients in the TFA were more likely to be treated with the two-stent strategy (Table 3). Thus, the TRA group had a significantly lower number of stents used, less use of FKB inflation, and greater use of POT or re-POT than the TFA group. After PSM, differences remained with regard to the proportion of patients being treated with the two-stent strategy in the TRA group versus the TFA group (14.2% vs. 23.7%, P < 0.001), number of stents used (1.8 ± 0.9 vs. 1.9 ± 1.1, P < 0.001), and use of FKB (27.5% vs. 36.5%, P < 0.001).

Table 3
Procedural characteristics and in-hospital adverse outcomes

Click for larger image
Click for full table
Download as Excel file

In the total study population, the TRA group, compared to the TFA group, had significantly lower rates of periprocedural complications (2.2% vs. 4.9%, P < 0.001), primarily driven by the lower rate of access site complications (0.5% vs. 1.7%, P = 0.002). These differences were maintained after PSM, with access site complications of 0.3% and 1.8% (P = 0.003) in the TRA and TFA groups, respectively. However, no significant differences existed between the TRA and TFA groups in other adverse events such as periprocedural MI, emergent repeat procedures, cardiogenic shock, and acute heart failure.

In addition, a temporal trend of increased use of TRA for bifurcation PCI was observed (Supplementary Fig. 2). The percentage of TRA procedures increased from 46.6% to 70.7% over the study period.

Long-term clinical outcomes

The median follow-up duration was 53 months. In the total population, the incidence of DOCO, the primary outcome, was significantly lower in the TRA group than in the TFA group (Table 4, Fig. 1A). In addition, the secondary outcomes patient-oriented composite outcome, target lesion revascularization, and target vessel revascularization were lower in the TRA group. However, the incidence of all adverse clinical events was similar between the two groups after PSM (Fig. 1B). The incidence of DOCO was not different between the TRA and TFA groups (6.3% vs. 7.1%, P = 0.639). Fig. 2 illustrates the results of the subgroup analysis of DOCO, based on vascular access, among the propensity score-matched population. There were no significant differences between access sites in the various subgroups. Furthermore, detailed subgroup analysis also revealed no significant differences between access sites based on bifurcation location, medina classification, and whether intravascular ultrasound was used (Supplementary Fig. 3).

Table 4
Cumulative incidence of adverse events at 5 years

Click for larger image
Click for full table
Download as Excel file

Fig. 1
Patient-oriented composite outcome based on vascular access in the total (A) and propensity score-matched populations (B).
HR = hazard ratio, CI = confidence interval, TFA = transfemoral access, TRA = transradial access.

Fig. 2
Subgroup analysis of device-oriented composite outcome.
CI = confidence interval, ACS = acute coronary syndrome, SA = stable angina, LM = left main, TRA = transradial access, TFA = transfemoral access.

DISCUSSION

We evaluated procedural differences, in-hospital adverse outcomes, and long-term clinical outcomes during a 5-year follow-up between TRA and TFA for bifurcation PCI by using multicenter, observational, real-world registry data in the second-generation DES era. The major study findings were: 1) compared to TFA, TRA was associated with a simple strategy involving less use of the two-stent and FKB techniques; 2) TRA was associated with lower in-hospital adverse outcomes, especially access site complications; 3) TRA and TFA had similar long-term clinical outcomes, despite differences in treatment strategy; and 4) an increasing trend was noted for using TRA for bifurcation PCI.

Previous large-scale randomized trials have revealed that TRA is superior to TFA in terms of access site bleeding, which ultimately reduced cardiac mortality, especially for patients with acute coronary syndrome.1, 2, 3 To reduce bleeding complications, TRA is recommended as a default strategy across the whole spectrum of ischemic heart disease.12, 13 A recent meta-analysis14 of LM PCI also demonstrated that TRA was associated with reduced bleeding and lower access site or vascular complications compared with TFA. This is consistent with our findings.

Recent technological advances in PCI devices have allowed TRA to be used in complex coronary artery diseases. The preference for TRA over TFA in PCI is growing. However, many operators hesitate to use TRA, especially during a complex procedure, likely because of poor backup support and the limited availability of larger devices. Regarding the radial artery diameter, most patients can be treated with a conventional 6 French guide during TRA.15 Nevertheless, the use of the two-stent strategy with a 6 French guide is limited, especially when two stents with larger diameters are inserted simultaneously. However, this limitation could be overcome by using a sheathless guide system or large-bore sheath, which provides a larger inner diameter without increasing the outer diameter.16, 17 Current guidelines recommend a one-stenting strategy with provisional side branch stenting as the initial approach for treating bifurcation lesions; the limitation of selecting the two-stent strategy should not affect clinical outcomes.18 In this study, use of the two-stent strategy was significantly lower in the TRA group, followed by FKB, even after adjusting for baseline clinical and angiographic characteristics. Despite the limitations of the two-stent strategy during TRA, the clinical outcomes were similar between the two groups. These findings suggest that TRA operators tend to prefer simple procedures that do not result in poor clinical outcomes.

Previous studies have evaluated the clinical benefits of using TRA versus TFA for bifurcation PCI.8, 9 The COBIS I registry, which enrolled patients from 2004 to 2006, revealed no significant differences between TRA and TFA for non-LM lesions in procedural success rates or in long-term safety and efficacy.8 The COBIS II Registry, which enrolled patients from 2003 to 2009 with LM and non-LM lesions, similarly demonstrated that TRA was superior to TFA in reducing bleeding complications and had comparable long-term clinical outcomes.9 However, these studies used first-generation DESs and may therefore have limited applicability. Our study confirmed that TRA was superior to TFA in reducing vascular complications and had similar clinical outcomes to bifurcation PCI with second-generation DESs. In addition, the rate of TRA was 30.2% in the COBIS I registry, 24.9% in COBIS II, and 56.9% in this study, highlighting a growing preference for TRA in bifurcation PCI.

Our study had several limitations. First, this was a non-randomized, retrospective, observational study; therefore, the potential for selection bias exists. Thus, PSM was conducted to adjust for confounding variables. This registry did not have detailed information about sheath size or the use of a sheathless guide on TRA due to its retrospective nature. Second, the choice of access site was largely determined by operator preference or hospital policy, which led to differences in baseline clinical and angiographic variables between the TRA and TFA groups. Despite conducting PSM, residual confounding factors could have affected the results. Third, the COBIS III Registry does not provide data on the rate of crossover from TRA to TFA or vice versa during bifurcation PCI. It was possible to change access sites from TRA to TFA during bifurcation PCI due to unpredictable complications. Accordingly, future prospective studies might be required which include vascular access and the rate of crossover during bifurcation procedure. Fourth, data on non-access site bleeding were unavailable. Finally, the registry did not include data on physiology-guided PCI, which may have an impact on clinical outcomes.

In conclusion, TRA showed similar long-term clinical outcomes compared to TFA for bifurcation PCI using second-generation DESs. Furthermore, our study also suggested that TRA enables operators to execute a simple strategy with fewer procedural complications compared to TFA. The use of TRA in bifurcation PCI is increasing. Nonetheless, further large randomized controlled studies are needed to confirm these findings. Overall, the results provide important clinical evidence to support the default use of TRA for bifurcation PCI.

SUPPLEMENTARY MATERIALS

Supplementary Fig. 1

Standardized mean difference before and after PSM.

Click here to view.^{(153K, doc)}

Supplementary Fig. 2

Temporal trend of the use of transradial access for bifurcation percutaneous coronary intervention.

Click here to view.^{(51K, doc)}

Supplementary Fig. 3

Further detailed subgroup analysis based on bifurcation location, medina classification, and whether intravascular ultrasound was used.

Click here to view.^{(178K, doc)}

Notes

Funding:This work was supported by the Korean Bifurcation Club (COBIS III) and the Korean Society of Interventional Cardiology (COBIS II and III). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Disclosure:The authors have no potential conflicts of interest to disclose.

Author Contributions:

Conceptualization: Lee JH, Youn YJ.
Data curation: Lee JH, Youn YJ.
Formal analysis: Lee JH, Youn YJ.
Funding acquisition: Youn YJ, Gwon HC.
Investigation: Lee JH, Youn YJ, Jeon HS, Lee JW, Ahn SG.
Methodology: Lee JH, Youn YJ, Jeon HS, Lee JW, Ahn SG.
Software: Lee JH, Youn YJ.
Validation: Lee JH, Youn YJ, Jeon HS, Lee JW, Ahn SG.
Visualization: Lee JH, Youn YJ.
Writing - original draft: Lee JH, Youn YJ.
Writing - review & editing: Lee JH, Youn YJ, Jeon HS, Lee JW, Ahn SG, Yoon J, Gwon HC, Song YB, Choi KH, Kim HS, Chun WJ, Hur SH, Nam CW, Cho YK, Han SH, Rha SW, Chae IH, Jeong JO, Heo JH, Lim DS, Park SJ, Hong MK, Doh JH, Cha KS, Kim DI, Lee SY, Chang K, Hwang BH, Choi SY, Jeong MH, Lee HJ.

References

1. Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet 2011;377(9775):1409–1420.
  PubMed
  
  CrossRef
1. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, Politi L, Rigattieri S, Pendenza G, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol 2012;60(24):2481–2489.
  PubMed
  
  CrossRef
1. Valgimigli M, Frigoli E, Leonardi S, Vranckx P, Rothenbühler M, Tebaldi M, et al. Radial versus femoral access and bivalirudin versus unfractionated heparin in invasively managed patients with acute coronary syndrome (MATRIX): final 1-year results of a multicentre, randomised controlled trial. Lancet 2018;392(10150):835–848.
  PubMed
  
  CrossRef
1. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J 2019;40(2):87–165.
  PubMed
  
  CrossRef
1. Writing Committee Members. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022;79(2):e21–129.
  CrossRef
1. Steigen TK, Maeng M, Wiseth R, Erglis A, Kumsars I, Narbute I, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation 2006;114(18):1955–1961.
  PubMed
  
  CrossRef
1. Latib A, Colombo A. Bifurcation disease: what do we know, what should we do? JACC Cardiovasc Interv 2008;1(3):218–226.
  PubMed
  
  CrossRef
1. Chung S, Her SH, Song PS, Song YB, Hahn JY, Choi JH, et al. Trans-radial versus trans-femoral intervention for the treatment of coronary bifurcations: results from Coronary Bifurcation Stenting Registry. J Korean Med Sci 2013;28(3):388–395.
  PubMed
  
  CrossRef
1. Chung S, Yang JH, Choi SH, Song YB, Hahn JY, Choi JH, et al. Transradial versus transfemoral intervention for the treatment of left main coronary bifurcations: results from the COBIS (COronary BIfurcation Stenting) II Registry. J Invasive Cardiol 2015;27(1):35–40.
  PubMed
1. Choi KH, Song YB, Lee JM, Park TK, Yang JH, Hahn JY, et al. Prognostic effects of treatment strategies for left main versus non-left main bifurcation percutaneous coronary intervention with current-generation drug-eluting stent. Circ Cardiovasc Interv 2020;13(2):e008543
  PubMed
  
  CrossRef
1. Louvard Y, Thomas M, Dzavik V, Hildick-Smith D, Galassi AR, Pan M, et al. Classification of coronary artery bifurcation lesions and treatments: time for a consensus!. Catheter Cardiovasc Interv 2008;71(2):175–183.
  PubMed
  
  CrossRef
1. Ferrante G, Rao SV, Jüni P, Da Costa BR, Reimers B, Condorelli G, et al. Radial versus femoral access for coronary interventions across the entire spectrum of patients with coronary artery disease: a meta-analysis of randomized trials. JACC Cardiovasc Interv 2016;9(14):1419–1434.
  PubMed
  
  CrossRef
1. Ahn SG, Lee JW, Youn YJ, Lee SH, Cho JH, Kang WC, et al. In-hospital outcome differences between transradial and transfemoral coronary approaches: data from the Korean Percutaneous Coronary Intervention registry. Catheter Cardiovasc Interv 2019;94(3):378–384.
  PubMed
  
  CrossRef
1. Goel S, Pasam RT, Raheja H, Gotesman J, Gidwani U, Ahuja KR, et al. Left main percutaneous coronary intervention-radial versus femoral access: a systematic analysis. Catheter Cardiovasc Interv 2020;95(7):E201–E213.
  PubMed
  
  CrossRef
1. Yoo BS, Yoon J, Ko JY, Kim JY, Lee SH, Hwang SO, et al. Anatomical consideration of the radial artery for transradial coronary procedures: arterial diameter, branching anomaly and vessel tortuosity. Int J Cardiol 2005;101(3):421–427.
  PubMed
  
  CrossRef
1. Meijers TA, Aminian A, van Wely M, Teeuwen K, Schmitz T, Dirksen MT, et al. Randomized comparison between radial and femoral large-bore access for complex percutaneous coronary intervention. JACC Cardiovasc Interv 2021;14(12):1293–1303.
  PubMed
  
  CrossRef
1. Youn YJ, Yoon J, Han SW, Lee JW, Sung JK, Ahn SG, et al. Feasibility of transradial coronary intervention using a sheathless guiding catheter in patients with small radial artery. Korean Circ J 2011;41(3):143–148.
  PubMed
  
  CrossRef
1. Albiero R, Burzotta F, Lassen JF, Lefèvre T, Banning AP, Chatzizisis YS, et al. Treatment of coronary bifurcation lesions, part I: implanting the first stent in the provisional pathway. The 16th expert consensus document of the European Bifurcation Club. EuroIntervention 2022;18(5):e362–e376.
  PubMed
  
  CrossRef