Prevention of Vascular Complications During Coronary Interventions: Choose a Different Access Route or Seal the Vessel?

To the Editor:

We read the article by Díaz de la Llera et al¹ with interest and would like to offer some comments. Reducing the incidence of complications during primary angioplasty, now that adjuvant therapy is widespread, is important.² Several studies^3-5 have reported that radial arterial access (RAA) offers interesting advantages compared to the transfemoral technique^3,4 and the authors¹ contribute further evidence in this regard. The success and the safety of RAA in trained hands is beyond question, and the clearest advantage compared to the femoral approach appears to be related to the smaller number of vascular complications.^3-5

Patients treated with fibrinolytics and glycoprotein IIb/IIIa inhibitors have a greater risk of hemorrhagic complications, especially at the puncture site. In this context, an alternative suggestion is the use of vascular closing devices (VCD) to reduce the number of complications. Resnic et al⁶ compared manual compression (MC) versus VCD in 3027 patients treated with angioplasty and found a 45% reduction in vascular complications with VCD. In the subgroup of patients who received glycoprotein IIb/IIIa inhibitors, complications with VCD were reduced to 57%, (5.51% with MC vs 2.34% with VCD; P=.02). Louvard et al⁷ also found a reduction in major hemorrhages at the puncture site from 7% to 2% with VCD. Applegate et al⁸ compared MC with the use of two different types of VCD in a series of 4525 patients who had undergone angioplasty and treatment with abciximab. In the patients in whom the use of such devices was successful, the rate of minor, major, and combined complications was 1.8% versus 0.8%, 1.35% versus 0.9% and 2.5% versus 1.5%, respectively. In the RACE⁹ study, no femoral complications occurred in patients who underwent angioplasty and treatment with glycoprotein IIb/IIIa inhibitors using a new VCD versus 3.4% in the control group (P=.03). Exaire et al¹⁰ found a low incidence of major hemorrhage and the need for transfusion (<1%) in patients from the TARGET study where either MC or various VCD were used. We emphasize that none of these studies was conducted exclusively in patients with primary angioplasty, although we consider that the main interest lies in facilitated and rescue angioplasty.

The learning curve for VCD is probably better than the one required for RAA, which means that its application can become widespread more easily. A trial comparing VCD with RAA would reveal the best strategy for patients with a high risk of presenting complications. Naturally, a cost-benefit analysis of the most suitable VCD and the impact of possible complications¹¹ is essential.

Finally, dogmas in medicine are dangerous and, in a field where concepts and technology are in continuous development, as in intervention cardiology, we should be very receptive and have on hand--almost literally in the case of RAA--new and better approaches and treatments to provide our patients with the best possible care.