ArticlesRadiation exposure in relation to the arterial access site used for diagnostic coronary angiography and percutaneous coronary intervention: a systematic review and meta-analysis
Introduction
Transradial access for diagnostic coronary angiography and percutaneous coronary intervention (PCI) is gaining popularity worldwide because of its proven advantages over the more traditional transfemoral access route, including reduced risk of complications associated with the access site and bleeding, improved patient comfort, early ambulation, and cost savings.1, 2, 3, 4 Moreover, in patients undergoing primary PCI for ST-elevation myocardial infarction, transradial access has been associated with a significant reduction in mortality and better net clinical benefits compared with transfemoral access.2, 5, 6 In a large meta-analysis of more than 760 000 patients, we noted that, compared with transfemoral access, transradial access was associated with a 78% reduction in bleeding (odds ratio [OR] 0·22, 95% credible interval [CrI] 0·16–0·29) and 80% reduction in transfusions (OR 0·20, 95% CrI 0·11–0·32). Overall, mortality was also reduced by 44% with transradial access (OR 0·56, 95% CrI 0·45–0·67).4 Despite these important advantages for patients, concerns about increased radiation exposure for both patient and operators have partly contributed to the slow uptake of transradial access in clinical practice, especially in the USA.7 Several observational studies and a few randomised trials have compared radiation exposure between transradial access and transfemoral access. Although the findings from some studies suggest that radiation exposure might be increased with transradial access, whether this is a real effect is unclear, because of the many limitations of observational data and the potential effect of the learning curve and operator proficiency. A large multicentre survey of more than 50 000 patients8 even reported that the radial route was associated with lower doses of radiation than the femoral route. So far, only one large-scale randomised trial has compared radiation exposure between the radial and femoral approaches.1 Despite this study, no global quantitative assessment of radiation exposure based on access site is available. Although data have accumulated since the inception of transradial access in 1989, the question of whether transradial access constitutes a real radiation hazard or not remains unanswered.
We therefore did a systematic review and meta-analysis with the aim of gathering data from all available randomised controlled trials and observational studies comparing radiation exposure between transradial access and transfemoral access, and assessing whether transradial access is associated with higher radiation exposure, using fluoroscopy time as a surrogate estimate of patient and operator radiation exposure, the kerma-area product as an estimate of patient exposure, and recorded operator dosimetry.
Section snippets
Search strategy and selection criteria
We did this systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement9 and followed a strict protocol (available on request).
We searched scientific literature databases for RCTs comparing transradial access and transfemoral access in terms of radiation exposure to the patient. We did a systematic search of PubMed, Embase, and the Cochrane Library, using various combinations of keywords such as “(trans)-radial”,
Results
From an initial screen of 1265 records, we reviewed and included 24 RCTs undertaken between 1995 and 2014 in our meta-analysis, which included data for 19 328 patients in 11 countries (figure 1). 18 studies were single-centred, and six were multicentred (table 1). Most of the studies were small—only four enrolled more than 1000 patients. The level of operator skill was heterogeneous across the 24 trials, with some trials done by highly experienced radial operators, but others only required that
Discussion
Although observational and randomised data for radiation dosimetry in cardiac catheterisation have been accumulating since 1989, whether transradial access is associated with a clinically significant increase in patient and operator radiation exposure compared with transfemoral access is unclear. Radiation exposure in interventional cardiology is of the utmost importance, because low but frequent doses of ionising radiation can cause effects including skin injuries, premature cataract
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