A randomized comparison of RadIal Vs. femorAL access for coronary intervention in ACS

(RIVAL)SS Jolly, S Yusuf, J Cairns, K Niemela, D Xavier, P

Widimsky, A Budaj, M Niemela, V Valentin, BS Lewis, A Avezum, PG Steg, SV Rao, P Gao, R Afzal, CD

Joyner, S Chrolavicius, SR Mehta on behalf of the RIVAL Steering committee

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DisclosuresDisclosures

Funded by: Funded by: Sanofi-Aventis and Bristol-Myers Squibb Sanofi-Aventis and Bristol-Myers Squibb (RIVAL sub-study of CURRENT/OASIS 7) (RIVAL sub-study of CURRENT/OASIS 7) Population Health Research InstitutePopulation Health Research Institute CANadian Network and Centre for Trials CANadian Network and Centre for Trials INternationally (CANNeCTIN, an initiative of INternationally (CANNeCTIN, an initiative of Canadian Institutes of Health Research) Canadian Institutes of Health Research)

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Bleeding is associated with Bleeding is associated with Death and Ischemic EventsDeath and Ischemic Events

Eikelboom JW et al. Circulation 2006;114(8):774-82.

HR 5.37 (3.97-7.26)

HR 4.44 (3.16-6.24)

HR 6.46 (3.54-11.79)

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Prior Meta-analysis of 23 RCTs of Radial vs. Femoral (N=7030)

Radial better Femoral better1.0

PCI Procedure Failure

Death

Death, MI or stroke

Major bleeding

1.31 (0.87-1.96)

0.74 (0.42-1.30)

0.71 (0.49-1.01)

0.27 (0.16-0.45)

Jolly SS, et al. Am Heart J 2009;157:132-40.

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RIVAL Study Objective

- To determine if Radial vs. Femoral access for coronary - To determine if Radial vs. Femoral access for coronary angiography/PCI can reduce the composite of death, MI, angiography/PCI can reduce the composite of death, MI, stroke or non-CABG major bleeding in ACS patientsstroke or non-CABG major bleeding in ACS patients

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NSTE-ACS and STEMI(n=7021)

Radial Access(n=3507)

Femoral Access(n=3514)

Primary Outcome: Death, MI, stroke or non-CABG-related Major Bleeding at 30 days

Randomization

RIVAL StudyRIVAL Study Design Design

Key Inclusion: •Intact dual circulation of hand required•Interventionalist experienced with both (minimum 50 radial procedures in last year)

Jolly SS et al. Am Heart J. 2011;161:254-60.

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Study Outcome DefinitionsStudy Outcome DefinitionsMajor Bleeding (CURRENT/OASIS 7)

• Fatal• > 2 units of Blood transfusion• Hypotension requiring inotropes• Requiring surgical intervention • ICH or Intraocular bleeding leading to significant vision loss

Major Vascular Access Site Complications

• Large hematoma• Pseudoaneurysm requiring closure• AV fistula• Other vascular surgery related to the access site

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Final RecruitmentFinal Recruitment

RIVAL Stand-AloneAfter CURRENT

N= 3190

RIVALTotal

N=7,021

RIVAL sub-study during OASIS 7/CURRENT

N= 3831 +

Follow-up complete in 99.9%CURRENT-OASIS 7. N Engl J Med. 2010;363:930-42.

Mehta SR, et al. Lancet. 2010; 376:1233-43.

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International StudyInternational Study

Middle East/Israel 239

Australia and New Zealand 64

North America 1614

South America 423

Asia 1117

Europe 3564

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Baseline CharacteristicsBaseline Characteristics

Radial Radial (n =3507)(n =3507)

Femoral Femoral (n =3514)(n =3514)

Mean Age (years) 62 62

Male (%) 74.1 72.9

Diabetes (%) 22.3 20.5

Diagnosis at presentation

UA (%) 44.3 45.7

NSTEMI (%) 28.5 25.8

STEMI (%) 27.2 28.5

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Therapies - Initial HospitalizationTherapies - Initial HospitalizationRadialRadial(n=3507)(n=3507)

%%

FemoralFemoral (n=3514) (n=3514)

%%

ASA 99.2 99.3

Clopidogrel 96.0 95.6

LMWH 51.5 51.8

UFH 33.3 31.6

Fondaparinux 10.9 10.8

Bivalirudin 2.2 3.1

GP IIb IIIa inhibitors 25.3 24.0

PCI 65.9 66.8

CABG 8.8 8.3

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Operator VolumeOperator VolumeProcedure CharacteristicsProcedure Characteristics

Radial Radial (n=3507) (n=3507)

Femoral Femoral (n=3514)(n=3514) HR (95% CI)HR (95% CI) PP

valuevalueOperator Annual Volume

PCI/year (median, IQR)

300 (190, 400)

300 (190,400)

Percent Radial PCI(median, IQR)

40 (25,70)

40 (25, 70)

PCI Success 95.4 95.2 1.01 (0.95-1.07) 0.83

• Vascular closure devices used in 26% of Femoral group

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Primary and Secondary OutcomesPrimary and Secondary Outcomes

RadialRadial(n=3507)(n=3507)

%%

Femoral Femoral (n=3514)(n=3514)

%%HRHR 95% CI95% CI PP

Primary OutcomeDeath, MI, Stroke, Death, MI, Stroke, Non-CABG Major Non-CABG Major BleedBleed

3.7 4.0 0.92 0.72-1.17 0.50

Secondary OutcomesDeath, MI, Stroke 3.2 3.2 0.98 0.77-1.28 0.90Non-CABG Major Bleeding 0.7 0.9 0.73 0.43-1.23 0.23

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Other OutcomesOther Outcomes

RadialRadial(n=3507)(n=3507)

%%

FemoralFemoral (n=3514)(n=3514)

%%HRHR 95% CI95% CI PP

Major Vascular Access Site Complications

1.4 3.7 0.37 0.27-0.52 <0.0001

TIMI Non-CABG Major Bleeding 0.5 0.5 1.00 0.53-1.89 1.00ACUITY Non-CABG Major Bleeding* 1.9 4.5 0.43 0.32-0.57 <0.000

1

* Post Hoc analysis

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Other OutcomesOther Outcomes

RadialRadial(n=3507)(n=3507)

%%

Femoral Femoral (n=3514)(n=3514)

%%HRHR 95% CI95% CI PP

Death 1.3 1.5 0.86 0.58-1.29 0.47MI 1.7 1.9 0.92 0.65-1.31 0.65Stroke 0.6 0.4 1.43 0.72-2.83 0.30Stent Thrombosis 0.7 1.2 0.63 0.34-1.17 0.14

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Other Outcomes Other Outcomes

RadialRadial(n=3507)(n=3507)

Femoral Femoral (n=3514)(n=3514) P P

Access site Cross-over (%) 7.6 2.0 <0.0001

PCI Procedure duration (min) 35 34 0.62

Fluoroscopy time (min) 9.3 8.0 <0.0001

Persistent pain at access site >2 weeks (%) 2.6 3.1 0.22

Patient prefers assigned access site for next procedure (%)

90 49 <0.0001

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Access Site Major BleedsAccess Site Major Bleeds

*All access site major bleeds actually occurred at femoral arterial site (in radial group due to cross-over or IABP)

HR 0.50 (95% CI 0.19-1.33)

*

<75 ≥75

FemaleMale

<2525-35>35

≤7070-142.5>142.5

Lowest TertileMiddle TertileHighest Tertile

NSTE-ACSSTEMI

Age

Gender

BMI

Radial PCI Volume/year by Operator

Radial PCI Volume by Centre

Clinical Diagnosis

Overall

0.25 1.00 4.00Radial better Femoral better

Hazard Ratio(95% CI)

0.79

0.36

0.83

0.54

0.021

0.025

Interactionp-value

Death, MI, Stroke or non-CABG major Bleed Subgroups: Primary OutcomeSubgroups: Primary Outcome

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0.25 1.00 4.00 16.00Radial better Femoral better

High MediumLow

High MediumLow

High MediumLow

HighMediumLow

HighMediumLow

0.021

0.013

0.538

0.019

0.003

Interactionp-valueHR (95% CI)

Primary Outcome

Death, MI or stroke

Non CABG Major Bleed

Major Vascular Complications

Access site Cross-over

Results stratified by High*, Medium* and Low*Results stratified by High*, Medium* and Low*Volume radial CentresVolume radial Centres

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No significant interaction by Femoral PCI center volume

Tertiles of Radial PCI Centre Volume/yr

*High (>146 radial PCI/year/ median operator at centre), Medium (61-146), Low (≤60)

NSTE/ACSSTEMI

NSTE/ACSSTEMI

NSTE/ACSSTEMI

NSTE/ACSSTEMI

NSTE/ACSSTEMI

50631958

50631958

50631958

50631958

50631958

3.55.2

2.74.6

0.83.2

1.00.9

3.83.5

3.83.1

3.42.7

1.21.3

0.60.8

1.41.3

0.25 1.00 4.00Radial better Femoral better

Hazard Ratio(95% CI)

0.025

0.011

0.001

0.56

0.89

Interactionp-value2N Radial Femoral

% %

Primary Outcome

Death, MI or stroke

Death

Non CABG Major Bleed

Major Vascular Complications

Outcomes stratified by STEMI vs. NSTEACSOutcomes stratified by STEMI vs. NSTEACSR I V A L

0.25 1.00 4.00Radial better Femoral better

Odds Ratio(95% CI)

Pre-RIVALRIVALCombined

Pre-RIVALRIVALCombined

Pre-RIVALRIVALCombined

Pre-RIVAL*RIVAL **Combined

0.2 0.7 0.5

0.61.41.0

2.33.22.8

2.8 1.3 2.3

1.2 0.9 1.0

2.5 3.73.1

3.3 3.23.3

4.12.73.5

0.40

0.41

0.72

0.67

Heterogeneityp-value

Radial(%) Femoral(%)

Non-CABG Major Bleeds

Major Vascular Access Complication

Death,MI or Stroke

Death, MI or Stroke (Radial Experts)

Updated Meta-analysis of RCTs Updated Meta-analysis of RCTs

0.002

<0.0001

0.17

0.005

P-value

*Radial Expert Centres defined as centres default approach radial or known expert radial centre ** High volume radial centres (highest tertile)

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ConclusionConclusion No significant difference between radial and femoral access No significant difference between radial and femoral access

in primary outcome of death, MI, stroke or non-CABG major in primary outcome of death, MI, stroke or non-CABG major bleedingbleeding

With radial access compared to femoral, rates of primary With radial access compared to femoral, rates of primary outcome appeared to be lower in high volume radial centres outcome appeared to be lower in high volume radial centres and STEMIand STEMI

Radial had fewer major vascular complications but similar Radial had fewer major vascular complications but similar PCI success PCI success

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ImplicationsImplications

Both radial and femoral approaches are safe and Both radial and femoral approaches are safe and effectiveeffective

Increasing experience may improve outcomes with Increasing experience may improve outcomes with radial accessradial access

Clinicians and patients may choose radial because Clinicians and patients may choose radial because of its similar efficacy and reduced vascular of its similar efficacy and reduced vascular complications complications

Available Online at Available Online at www.lancet.comwww.lancet.com

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AcknowledgementsAcknowledgementsRIVAL Investigators from 158 sites in 32 countriesRIVAL Investigators from 158 sites in 32 countries

Steering Committee

S.S. Jolly (PI) S.R. Mehta (PI)

S. Yusuf (Chair) C.D. Joyner (Adjudication Chair)

S. Chrolavicius M. Keltai

A. Avezum F. Lanas

A. Budaj B. Lewis

J. Cairns K. Niemela

R. Diaz S.V. Rao

V. Dzavik P. G. Steg

M.G. Franzosi V. ValentinC. B. Granger P. Widimsky

D. Xavier

DMCP. Sleight (Chair)) D. R. Holmes Jr.

J.L. Anderson D.E. Johnstone

D. DeMets

J. Hirsh

Project Office Study Team

S. Chrolavicius (Project Manager)

B. Jedrzejowski (Research Coordinator)

M. Lawrence (Events Adjudication Coordinator)

R. Manojlovic, L. Mastrangelo, E. Pasadyn, C. Agrippa, M. McClelland, (former ) C. Cramp, C. Horsman, A. Robinson, L. Blake, W. Chen, S. Diodato, A. Lehmann, T. Sovereign, L.Wasala

Statisticians and Biometrics

R. Afzal (IDMC-Associated)

P. Gao

L. Xu

X. Yang

E. Dai