Chronic total occlusions (CTO) are one of the most challenging scenarios in percutaneous coronary intervention (PCI).1 Currently, transfemoral access is the most frequently used vascular approach in CTO-PCI,2–4 as it enables use of larger-bore guiding catheters and increases backup support and maneuverability.

The development of new materials and techniques over the past few years has substantially improved the efficacy of CTO-PCI5,6 and contemporary registries report success rates of more than 80%, mainly employing transfemoral access.7,8

The adoption of a transradial approach in CTO-PCI is progressively gaining attention as it provides comparable success rates in more simple lesions, while significantly reducing bleeding and access site complications.4,9,10 Compared with transfemoral access, transradial PCI allows early ambulation, facilitates same-day hospital discharge, and has been linked to greater cost reduction.11–13 However, consistent data on the outpatient management of patients undergoing transradial CTO-PCI are currently lacking.

The aim of our study was to evaluate the safety and feasibility of a transradial access PCI program in CTO and its impact on length of hospital stay and same-day hospital discharge.

From January 2015, a prospective registry of CTO-PCI procedures was created through the Iberian registry, including 31 hospitals in 2 different European countries and endorsed by the Spanish Association of Interventional Cardiology and the Spanish Society of Cardiology. The Iberian CTO Registry was approved by the Ethics Committee of Valladolid-Este Health Area. Each hospital entered the data using an online platform. Informed consent for this study was not needed as all data were properly anonymized, complying with the requirements of the Law on Data Protection, and were accessible only to participating operators and registry coordinators. Informed consent for procedures was always obtained before CTO-PCI.

Between January 2015 and March 2021, 2687 percutaneous CTO revascularization procedures were consecutively included. The criteria for CTO-PCI were similar among participants and required the presence of viability in the corresponding myocardial segments and at least 1 of the following: inducible ischemia, clinically symptomatic angina, or occlusion of a proximal coronary vessel associated with left ventricular systolic dysfunction.

Accurate information on vascular access was assessed and 2 cohorts were compared according to the presence or absence of at least 1 femoral puncture. Hence, the radial cohort was composed of the addition of 1 radial or 2 radial access procedures and the femoral cohort included 1 femoral, 2 femoral or 1 femoral and 1 radial access procedures. Vascular access was performed by physician preferences following their own local protocols.

A total of 2550 procedures were recorded with accurate access site information, consisting of 896 procedures included in the transradial cohort and 1654 in the transfemoral cohort (figure 1).

Figure 1.

Central illustration. Study diagram and selection of cases.

(0.21MB).

The main findings of our study are summarized as follows: first, the transradial approach for CTO-PCI is safe and reduces in-hospital complications and length of stay. Second, transradial access is feasible and allows percutaneous revascularization of complex CTO lesions with no compromise in success rates compared with the transfemoral approach.

Although no differences in Syntax or J-CTO scores were assessed, transradial procedures had a lower rate of previous ICP or CABG, and fewer cases with more than 1 CTO or previous attempts. This suggests that easier cases could be more prone to be scheduled for transradial access a priori (even showing a higher success rate in the transradial cohort), but after we adjusted the analysis according to the predicted difficulty, either by selecting J-CTO>2-only cases or by selecting hybrid or retrograde procedures, we found no difference in the success rate. Another explanation could be that this higher proportion of previous PCI or CABG might not reflect a higher anatomical complexity a priori, but rather a lack of available vascular access, as both transradial PCI and CABG may limit the patency of the radial artery for subsequent procedures.

Currently, transradial PCI represents the vascular access of choice as it consistently improves outcomes across the whole spectrum of CAD.4,9,10,18,19 Nevertheless, CTO-PCI is still frequently performed via the femoral artery in routine clinical practice.

Previous studies have evaluated the feasibility of a transradial approach in CTO-PCI with encouraging results.3,4,9,10 In a single-center experience including 585 patients, Tanaka et al.3 reported similar success rates with either transradial or transfemoral CTO-PCI, although revascularization was less frequently achieved in patients with more complex lesions (J-CTO score> 2) treated via transradial access.

In the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO),7 although no differences in procedural success rate were observed, transradial procedures showed lower complexity scores than transfemoral procedures. On the other hand, a recent multicenter registry including more than 5000 patients described higher procedural success rates with a transradial vs a transfemoral approach (79.1% vs 75%, P=.001). However, information on lesion complexity was not recorded in that study.2 Technical success was similar for transradial and transfemoral CTO-PCI in 1253 patients in the RECHARGE registry, even in more complex lesions.9 Of importance, access-site selection in these previous studies was made at the operatoŕs discretion, considering the patient́s anatomical and clinical characteristics and so individual bias cannot be excluded.

Very recently, a well-designed controlled clinical trial compared transradial and transfemoral access for CTO-PCI in 616 patients.20 As far as we know, this was the first randomized controlled trial attempting to answer this important question. The results showed no differences in the success rate with fewer vascular complications in the transradial cohort, but in this study, although all procedures were performed by 4 highly experienced operators (with> 100 CTO-PCI per year each), the representation of more complex techniques for CTO-PCI such as hybrid or retrograde approach were underrepresented, and 94% of transradial and 96% of transfemoral procedures were performed via the antegrade approach with antegrade wiring and antegrade dissection and reentry.

Until recently, overnight observation after PCI was the standard of care. However, a same-day discharge strategy is increasingly being adopted worldwide, as it provides comparable safety results and significantly reduces health care-associated costs, while increasing in-patient bed capacity and patient comfort.21–23 Transradial PCI facilitates same-day discharge as it allows early mobilization and reduces the risk of access-site complications. Indeed, substantial cost savings have been described with transradial compared with transfemoral access.11–13 Ambulatory management following PCI has been previously assessed in all-comer populations including patients with complex coronary artery disease.11,24 Previously, few single-center studies had evaluated same-day discharge in CTO-PCI,25,26 but recently, an analysis of the British Cardiovascular Intervention Society evaluating 21 330 patients who underwent CTO-PCI from 2007 to 2014 found transradial access as the main independent factor associated with same-day discharge.27

A transradial approach for CTO-PCI is safe and effective in most CTO lesions and reduces postprocedural complications. The adoption of a transradial protocol for CTO-PCI may have important implications for health care resource management as it shortens the length of hospital stay and enables same-day hospital discharge in an increasing number of elective procedures.

The REBECO Registry is funded by an unconditional grant from the Spanish Association of Interventional Cardiology and the Spanish Society of Cardiology.

A. Diego-Nieto, J. Núñez-García and J. Martín-Moreiras designed the study, collected records, and supervised the work overall. A. Diego-Nieto performed the statistical analysis and wrote the first draft of the manuscript. I. Amat-Santos and J.A. Fernández-Díaz coordinate the registry. All authors have performed procedures, recorded data in the registry, and reviewed and approved the final manuscript.

I. Amat-Santos is proctor for Boston Scientific, P. Salinas-Sanguino received speaker fees and support for attending meetings from Boston Scientific, Biomenco and Abbott; A. Regueiro received speaker fees from Terumo, Cordis and Boston Scientific and participates on Boston Scientific advisory board; M. Pan received speaker fees from Abbott, Asahi, Boston Scientific and Phillips; N. Gonzalo receives a research grant, speaker and consulting fees from Abbott Vascular and speaker fees from Boston Scientific; A. Jurado-Román receives speaker fees from Biomenco and Boston Scientific; M. Sabaté received consulting fees from Abbott Vascular and iVascular; S. Ojeda received consulting fees from WorldMedical, Edwards Lifesciences and Medtronic and speaker fees from Abbott Vascular, Boston Scientific, Terumo and Phillips, and participates on Medtronic and Edwards Lifesciences advisory boards; J. Sanchis received speaker fees from Biotronik, Abbott Vascular and Boston Scientific; J. Escaned received speaker fees from Abbott, Boston Scientific and Phillips, and participates on Boston and Phillips advisory boards; J. Martín-Moreiras is proctor for Boston Scientific, World Medica and Teleflex. None of the remaining authors declare conflicts of interest.

J. Sanchis is the Editor-in-Chief of Revista Española de Cardiología; the journal's editorial procedures have been followed to guarantee impartial handling of the manuscript.