Femoral versus Radial Approach for Primary Percutaneous Intervention in Cardiogenic Shock: A Subanalysis from the ECLS-SHOCK Trial

M. Abumayyaleh (Mannheim)¹, H. Thiele (Leipzig)², T. Rassaf (Essen)³, A.-A. Mahabadi (Essen)³, R. Lehmann (Langen)⁴, I. Eitel (Lübeck)⁵, C. Skurk (Berlin)⁶, P. M. Clemmensen (Hamburg)⁷, M. Hennersdorf (Heilbronn)⁸, I. Voigt (Essen)⁹, A. Linke (Dresden)¹⁰, E. P. Tigges (Hamburg)¹¹, P. Nordbeck (Würzburg)¹², C. Jung (Düsseldorf)¹³, P. Lauten (Bad Berka)¹⁴, H.-J. Feistritzer (Leipzig)², J. Pöss (Leipzig)², M. Behnes (Mannheim)¹, D. Dürschmied (Mannheim)¹, S. Desch (Leipzig)², A. Freund (Leipzig)², U. Zeymer (Ludwigshafen am Rhein)¹⁵, I. Akin (Mannheim)^1
1Universitätsklinikum Mannheim GmbH I. Medizinische Klinik Mannheim, Deutschland; ²Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; ³Universitätsklinikum Essen Klinik für Kardiologie und Angiologie Essen, Deutschland; ⁴Asklepios Klinik Langen Medizinische Klinik I, Kardiologie und Angiologie Langen, Deutschland; ⁵Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; ⁶Charité - Universitätsmedizin Berlin CC 11: Med. Klinik für Kardiologie Berlin, Deutschland; ⁷Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ⁸SLK-Kliniken Heilbronn GmbH, Klinikum am Gesundbrunnen Klinik für Innere Medizin I Heilbronn, Deutschland; ⁹Elisabeth-Krankenhaus Essen GmbH Klinik für Akut- und Notfallmedizin Essen, Deutschland; ¹⁰Herzzentrum Dresden GmbH an der TU Dresden Klinik für Innere Medizin und Kardiologie Dresden, Deutschland; ¹¹Asklepios Klinik St. Georg Kardiologie & internistische Intensivmedizin Hamburg, Deutschland; ¹²Universitätsklinikum Würzburg Medizinische Klinik und Poliklinik I Würzburg, Deutschland; ¹³Universitätsklinikum Düsseldorf Klinik für Kardiologie, Pneumologie und Angiologie Düsseldorf, Deutschland; ¹⁴Zentralklinik Bad Berka GmbH Klinik für Kardiologie und Internistische Intensivmedizin Bad Berka, Deutschland; ¹⁵Institut für Herzinfarktforschung Ludwigshafen am Rhein, Deutschland

Background

Cardiogenic shock (CS) is a life-threatening complication of acute coronary syndromes (ACS). Early revascularization with treating the culprit lesion improves survival. Nevertheless, the impact of access site (femoral vs. radial) on outcomes in infarct-related CS also in conjunction with extracorporeal life support (ECLS) remains unclear.

Methods

This subanalysis of the ECLS-SHOCK trial included patients with infarct-related CS treated with or without ECLS, divided into femoral and radial access groups. The primary endpoint was 30-day mortality. Secondary endpoints included renal replacement therapy (RRT), repeat revascularization, reinfarction, rehospitalization for congestive heart failure, and poor neurological outcome (Cerebral Performance Category [CPC] 3-5) within 30 days. Safety outcomes included bleeding and peripheral vascular complications.

Results

Among 415 patients, percutaneous coronary intervention (PCI) was initially intended through femoral (N=304; 72.9%) or radial (N=111; 26.6%) access. In the radial group, 25 patients (22.5%) switched to femoral access, while 3 patients (1%) in the femoral group switched to radial access prior to or after coronary angiography. At 30 days, the overall mortality rate was higher in the femoral group compared to the radial group (52.0% vs. 37.8%) with a relative risk (RR) of 1.37; 95%-confidence interval [CI], 1.06-1.78; p=0.011 with no significant differences in the crude rates of secondary and safety endpoint. In the as-treated ECLS arm, 7.8% switched from radial to femoral, while 7.5% switched in the as-treated conservative arm from radial to femoral for or after coronary angiography. Mortality rates were higher in the femoral group for both ECLS (52.7% vs. 26.8%; p=0.003; RR 1.96 [95% CI, 1.16-3.32]) and conservative arms (52.2% vs. 37.5%; p=0.074; RR 1.39 [95% CI, 0.94-2.06]). In a multivariate analysis, femoral access was associated with a strong trend for predicting adjusted 30-day mortality (RR, 1.69; 95% CI, 0.99-2.86; p=0.051).

Conclusions

In myocardial infarction related CS, nearly one-fifth of patient’s with intended radial access switched to femoral, which was associated with a higher mortality but similar safety outcomes regardless of ECLS or conservative treatment by univariate analysis. In multivariate analysis, femoral access was associated with a trend to adversely affect 30-day mortality.