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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e52 CLINICAL STATEMENTS AND GUIDELINES ease,” which has provided guidance that reflects the current state of the evolving evidence.3 10 GENERAL PROCEDURAL ISSUES FOR PCI 10.1 Radial and Femoral Approaches for PCI Recommendations for Radial and Femoral Approaches for PCI Referenced studies that support the recommendations are summarized in Online Data Supplement 23. COR LOE Recommendations 1 A 1. In patients with ACS undergoing PCI, a radial approach is indicated in preference to a femoral approach to reduce the risk of death, vascular complications, or bleeding.1-4 1 A 2. In patients with SIHD undergoing PCI, the radial approach is recommended to reduce access site bleeding and vascular complications.4-7 Synopsis Over the past decade, the proportion of patients undergoing radial artery catheterization and PCI has increased exponentially.8 Patients prefer the transradial approach,9 and this approach offers the advantage of earlier time to ambulation, lower rate of vascular and bleeding complications, and improved cardiovascular outcomes in patients with ACS.4 An important caveat to radial access trials1,2,9 is that the treating physicians were required to have experience in radial artery access, and therefore, it is not surprising that femoral crossover rates were notably low among patients assigned to radial access.1-4 For this reason, it is encouraged that all operators gain experience in radial artery access so that they may ultimately acquire the skills needed to have expertise with this approach. The decision to use the transradial approach should be tempered with the possibility that the radial artery may be needed for bypass grafting in the future. In patients for whom there is a high likelihood of future CABG, the choice of vascular access may require discussion with the patient and the cardiac surgeon. In centers where expertise in the transradial approach is unavailable, or in those patients who are unable to get radial artery catheterization because of anatomic or clinical limitations, femoral artery access remains the default strategy. Recommendation-Specific Supportive Text 1. The MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX Access) trial2 demonstrated a significantly lower rate of the coprimary endpoint of net adverse clinical events (30-day death, nonfatal infarction and stroke, and non-CABG major bleeding) among patients with ACS randomized to the transradial approach than among those randomized to the transfemoral approach. This difference was driven by a lower rate of bleeding events and a lower 30-day mortality rate. A prespecified subgroup analysis of patients with STEMI enrolled in RIVAL (Trial of Trans-radial versus Trans-femoral Percutaneous Coronary Intervention Access Site Approach in Patients with Unstable Angina or Myocardial Infarction Managed with an Invasive Strategy) demonstrated a lower mortality rate at 30 days with transradial access. A meta-analysis of the RCT supported these findings and reported lower rates of mortality and bleeding with radial access in patients with ACS.3,4 Although the SAFARI-STEMI (Safety and Efficacy of Femoral Access versus Radial for Primary Percutaneous Intervention in ST-Elevation Myocardial Infarction) trial showed no difference in 30-day mortality rate between radial and femoral access, this trial was stopped early for futility and enrolled less than half its planned sample size.10 Of note, in patients with a high likelihood of needing future CABG, radial access of the dominant artery will allow preservation of the nondominant radial artery for use as a bypass graft. 2. In patients undergoing coronary angiography or PCI without ACS, the transradial approach significantly reduces bleeding and vascular access site complications but has not been shown to significantly reduce rates of MACE or mortality.4 10.2 Choice of Stent Type Recommendation for Choice of Stent Type Referenced studies that support the recommendation are summarized in Online Data Supplement 24. COR LOE Recommendation 1 A 1. In patients undergoing PCI, DES should be used in preference to BMS to prevent restenosis, MI, or acute stent thrombosis.1-4 Synopsis Earlier studies comparing outcomes with first-generation DES and BMS reported an increase in late stent thrombosis and increased mortality rate with DES.5-8 Over the past 2 decades, there has been a significant evolution in DES technology, including the optimization of drug, polymer, and stent design, which has supported the safety as well as the efficacy of newer DES. To make sense of the small absolute differences between stent types, several large meta-analyses have been completed1-4 and have suggested that the currently available DES have higher efficacy and safety and lower restenosis rates than both first-generation DES and BMS.1-4 Downloaded from http://ahajournals.org by on October 7, 2026