Femoral Versus Radial Artery Access for CTO PCIs: Is This the Final Round?

Historically, cardiac catheterization has been performed via transfemoral access (TFA). Although TFA remains necessary in multiple diagnostic and interventional settings, this technique has been associated with vascular access site complication rates ranging from 2% to 6%, prolonged hospital stay, and more deaths compared with radial artery access. Furthermore, safe utilization of the femoral artery can be compromised by abdominal obesity, atherosclerosis at the puncture site, and antithrombotic therapy, all which increase the bleeding risk.1 In the last decade, transradial artery access (TRA) emerged as the recommended approach for percutaneous coronary interventions (PCI), particularly in the acute setting where TRA compared with TFA showed a clear reduction of bleeding complications and mortality.2,3 For these reasons, a “radial first” approach is recommended in both European and American guidelines. For patients with stable ischemic heart disease, TRA has produced less bleeding than TFA, though without a mortality benefit.6,7 Importantly, most stable ischemic heart disease studies comparing access sites have excluded patients with complex coronary lesions. The evidence supporting TRA PCI feasibility and performance in chronic total occlusions (CTO) comes from observational studies and 1 randomized trial. The latter, the COLOR trial (Complex Large-Bore Radial Percutaneous Coronary Intervention [PCI] Trial), showed that for complex PCI procedures requiring large-bore access, TRA compared with TFA is associated with a significant reduction in clinically relevant access site bleeding and vascular complications, without differences in procedural success rates. In this study, <60% of lesions treated were CTO