Predictors of radial to femoral artery crossover during primary percutaneous coronary intervention in ST-elevation myocardial infarction: A systematic review and meta-analysis

Background: In contrast to traditional femoral artery access, radial artery access for primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) is associated with reduced mortality and bleeding but has higher crossover rates. Therefore, factors associated with crossover warrant exploration as crossover due to technical challenges associated with the radial route may be mitigated. Objective: The objective of this study was to identify predictors of radial access failure or crossover to femoral access in PPCI. Methods: A systematic review and meta-analysis was undertaken according to the Joanna Briggs Institute Systematic Reviews Checklist with searches conducted in Medline, EMBASE, CINAHL, and SCOPUS databases. Inclusion criteria for this study included patients with STEMI; PPCI; and primary research identifying predictors of radial access failures and/or crossovers, published in English, and after 2010. This study was registered with PROSPERO (CRD42020167122). Statistical analysis was performed using IBM SPSS Statistics for Windows version 26.0 (IBM Corp, Armonk, NY) and RevMan version 5.4 (Cochrane Collaboration, London, United Kingdom) with meta-analysis conducted by using the DerSimonian and Laird random-effects method. The National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was utilised for quality and risk of bias assessment, with EndNote software used for citations. Results: Eight observational studies met inclusion criteria, comprising 12,621 patients. Risk of bias of these studies was assessed using the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The mean age was 61.2 ± 12.0 years, and 75.3% were male. Crossover from transradial to transfemoral artery occurred in 529 (4.2%) patients. Reasons for radial access failure included failed puncture (35.3%), peripheral occlusion or tortuosity (24.5%), and radial artery spasm (20.1%). Predictors of crossover included older age (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.44–2.65; p < 0.001), female sex (OR, 2.10; 95% Cl, 1.58–2.80; p < 0.001), weight ≤65 kg (OR, 2.95; 95% CI, 1.95–4.46; p < 0.001), and previous percutaneous coronary intervention (OR, 2.80; 95% Cl, 1.74–4.52; p < 0.001). Conclusion: Older age, female sex, weight ≤65 kg, and previous percutaneous coronary intervention were predictors of crossover or failure from the radial to femoral artery. As these predictors are known to be associated with high bleeding and mortality, they should not preclude attempting a radial-first approach in all patients with STEMI. However, as these results were unadjusted, this study warrants further research to thoroughly investigate predictors of radial artery crossover.