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CLINICAL STATEMENTS AND GUIDELINES April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e810 7 CATHETERIZATION LABORATORY CONSIDERATIONS IN ACS 7.1 Vascular Access Approach for PCI Recommendation for Vascular Access Approach for PCI Referenced studies that support recommendation are summarized in the Evidence Table. COR LOE Recommendation 1 A 1 In patients with ACS undergoing PCI, a radial approach is preferred to a femoral approach to reduce bleeding, vascular complications, and death.*1–6 *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”7 Synopsis The radial artery has become the preferred vascular access site for patients undergoing cardiac catheterization and PCI.8,9 Transradial access is associated with lower mortality, bleeding, and vascular complications in patients treated for ACS.5 In addition, patients prefer radial access because it allows earlier ambulation and causes less discomfort than femoral access.9 A caveat is most trials comparing radial versus femoral access had very low crossover rates because they required operators with expertise in radial access.3 The choice of radial access has to be weighed against the possibility that the radial artery could be used as a bypass conduit for CABG surgery.10 In sites where surgeons routinely utilize the radial artery as a bypass conduit, consideration should be given on the choice of vascular access and future use of radial artery for the cardiovascular surgical team. Although the radial artery is the most widely studied wrist access site, the use of alternative sites in the upper extremity, including the ulnar and distal radial arteries have yielded similar outcomes.11,12 Transfemoral access, preferably with the use of ultrasound guidance, should be considered in patients in whom temporary MCS is planned and is the default alternative access site among patients in whom the radial artery cannot be used due to clinical, anatomical, or technical reasons.13 Recommendation-Specific Supportive Text 1 RCTs have consistently demonstrated the ben- efit of radial access in comparison with femoral access among patients treated for ACS. A metaanalysis using individual patient data from 7 highquality RCTs (48.6% with NSTE-ACS; 46.2% with Figure 8. Selection and Timing of an Invasive Strategy in NSTE-ACS. Figure 8 summarizes the recommendations in the 2025 ACS Guideline for a routine or selective invasive approach in NSTE-ACS. It is not meant to encompass every patient scenario or situation, and clinicians are encouraged to use a Heart Team approach when care decisions are unclear and to see the accompanying supportive text for each recommendation. Colors correspond to Class of Recommendation in Table 2. GRACE indicates Global Registry of Acute Coronary Events; HF, heart failure; NSTE-ACS, non–ST-segment elevation acute coronary syndromes; Tn, troponin; TIMI, Thrombolysis in Myocardial Infarction; VF, ventricular fibrillation; and VT, ventricular tachycardia. Adapted with permission from Lawton et al.18 Copyright 2022 American Heart Association, Inc., and American College of Cardiology Foundation. Downloaded from http://ahajournals.org by on October 7, 2026