Background

While radial access (RAD) is recommended as the gold standard for percutaneous coronary intervention (PCI), rotational atherectomy (ROTA) is still often performed via femoral access (FEM). Concerns regarding sheath and guiding size but also delivery of the burr as well as the placement of a temporary pacemaker may influence that decision. Available data that compare procedural parameters and outcome of ROTA via the radial and femoral access are extremely limited and stem from studies with small patient numbers. 

Our aim was to compare feasibility and procedural parameters as well as complication rates in patients treated by ROTA either via the radial or femoral access. 

Methods & Results

We retrospectively analyzed all patients (n=427) planned to undergo ROTA at our institution between 03/2013 und 06/2021 either via RAD (n=171) or via FEM (n=256). Procedural success defined as successful performance of ROTA was equal in both groups (97.6%). Ad-hoc interventions were more frequent in the radial access group (RAD 46.1%, vs. FEM 27.7%; p<0.001). Whereas sheath (RAD: 6F 39.5%, 7F 60.5% vs. FEM: 6F 16.1%, 7F 76.7%, 8F 7.2%, p<0.001) and guiding sizes (RAD: 6F 46.8%, 7F 53.2% vs. FEM: 6F 25.4%, 7F 71.1%, 8F 3,5%; p<0.01) were significantly smaller in the RAD group, burr size did not differ between the groups (p=0.51). Fluoroscopy time (24:51±13:58min vs. 30:43±19:18 Min; p<0.001) as well as procedure duration was longer in the FEM group (1:27:24±0:34:53hours vs. 1:36:50±0:44:33hours; p=0.018). A temporary pacemaker was more often inserted in the FEM group (27.3% vs. 13.8%, p=0.001), even though the frequency of treating the RCA (RAD 25.7% vs. FEM 34.4%; p=0.065) or LCX (RAD 18.7% vs. FEM 23.8%; p=0.22) did not differ between the groups. Periprocedural complications defined as coronary perforation, stuck of the burr, slow- or no-reflow phenomenon, ECG alterations including AV block or hemodynamic instability needing any kind of vasopressors, wire complications or periprocedural death were equally frequent in both groups, mainly driven by arrhythmias or hemodynamic instability (RAD 13.2% vs. FEM 16.5%; p=0.36). 

The FEM group showed a higher rate of access-related complications defined as a composite of either bleeding, aneurysm, AV fistula or ischemia (12.5% vs. 4.1%, p=0.003). This was mainly driven by bleeding (10.9% vs. 3.5%, p=0.005). BARC 3a (3.9%) and 3b bleeding (1.6%) and the need for transfusion (2.0%) were limited to the FEM group. FEM was an independent predictor for access-related complications (OR 3.05; 95% CI 1.29-7.22), while sheath (p=0.575) or guiding size (p=0.647) was not different in patients with or without access related complications. 

Conclusion:

In patients undergoing ROTA, the transradial access should be preferred whenever possible. Success rates and burr size are equal to the transfemoral access, while clinically relevant access-site related complications are significantly lower.