Access Site in Coronary Angiography and Percutaneous Coronary Intervention

Abstract

Coronary angiography and percutaneous coronary intervention (PCI) are cornerstone procedures in the diagnosis and management of coronary artery disease, traditionally performed via transfemoral access (TFA). Over the past two decades, transradial access (TRA) has emerged as an alternative approach, supported by evidence demonstrating reduction in bleeding, vascular access complications, and even mortality, particularly in patients with acute coronary syndromes. Despite widespread adoption, important gaps remain regarding the comparative safety, assessment and management of complications, and cost effectiveness of TRA vs TFA across diverse clinical settings. This Doctorate in Philosophy thesis evaluates vascular access strategies for coronary angiography and PCI through a comprehensive program of epidemiologic research integrating a systematic review and meta-analysis, observational studies, a prospective diagnostic evaluation study, economic modeling, and randomized clinical trial development. First, a systematic review and meta-analysis synthesizes randomized evidence comparing TRA and TFA in patients undergoing PCI for ST-elevation myocardial infarction, with a focus on short term mortality. Second, a large retrospective cohort study examines the incidence and predictors of catheter-induced coronary artery dissection (a rare but potentially catastrophic complication) by comparing TRA and TFA in a real-world practice. Third, a prospective cohort study evaluates the diagnostic accuracy of bedside point-of-care ultrasound for detecting access site complications which addresses an important gap in post-procedural management of patients. Fourth, a cost effectiveness analysis assesses TRA versus TFA in acute myocardial infarction from the perspective of the Canadian publicly funded healthcare system by incorporating clinical outcomes, cost, and quality-adjusted life-years. Finally, the thesis includes the design and statistical analysis plan of a multicentre randomized clinical trial evaluating post-procedural anticoagulation for the prevention of radial artery occlusion (i.e. the most common complication following TRA).

Collectively, this thesis applies rigorous epidemiological and health economic methods to evaluate clinically relevant questions in interventional cardiology thereby generating evidence to inform procedural practice, optimize patient outcomes, and guide future clinical trials and health system decision making.