Practice Update: Cardiology

CARDIAC IMAGING 16

Acute kidney injury after radial or femoral access for invasive acute coronary syndrome management JACC: Journal of the American College of Cardiology Take-home message

RA and 712 patients (17.4%) with FA (odds ratio [OR]: 0.87; 95% confidence interval [CI]: 0.77 to 0.98; p = 0.0181). A >25% sCr increase was noted in 633 patients (15.4%) with RA and 710 patients (17.3%) with FA (OR: 0.87; 95% CI: 0.77 to 0.98; p = 0.0195), whereas a >0.5 mg/dl absolute sCr increase occurred in 175 patients (4.3%) with RA versus 223 patients (5.4%) with FA (OR: 0.77; 95% CI: 0.63 to 0.95; p = 0.0131). By implementing the Kidney Disease Improving Global Outcomes cri- teria, AKI was 3-fold less prevalent and trended lower with RA (OR: 0.85; 95% CI: 0.70 to 1.03; p = 0.090), with stage 3 AKI occurring in 28 patients (0.68%) with RA versus 46 patients (1.12%) with FA (p = 0.0367). Post-intervention dialysis was needed in 6 patients (0.15%) with RA and 14 patients (0.34%) with FA (p = 0.0814). Stratified analyses suggested greater benefit with RA than FA in patients at greater risk for AKI. CONCLUSIONS In ACS patients who underwent invasive management, RA was associated with a reduced risk of AKI compared with FA. Acute kidney injury after radial or femoral access for invasive acute coronary syndrome management: AKI-MATRIX. J Am Coll Cardiol 2017 May 11;[EPub Ahead of Print], G Andò, B Cortese, F Russo, et al. would lead to fewer AKI events have been debated. An intriguing theory has been the avoidance of shifting and embolization of plaque material with a femoral approach. However, manipulation of the aortic arch and ascending aorta still occurs with a radial approach. The current study nowmoves an alternative theory forward: bleeding events, and, more so, blood volume shifts, including blood transfusions, increase the risk of AKI. A radial approach henceforth decreases the risk of AKI via its well-known risk-mitigating effect on bleeding. Whether this holds true only in acute coronary syndrome patients, as studied here, or in general is not well-de- fined at this point. Taken together, a radial approach has multiple benefits, and these are seemingly related. Overall, the balance is in its favor, and one might consider it as the default approach in this day and age. Back to the beginning!

• This study sought to determine why the risk for acute kidney injury (AKI) during acute coronary syndrome (ACS) is lower with renal access (RA) compared with femoral access (FA). Of 8404 patients, 15.4% developed AKI with RA versus 17.4% with FA (P = .0181). In 15.4% of RA patients and 17.3% of FA patients, serum creatine levels increased by >25%. Increases in absolute serum creatine >0.5 mg/dL occurred in 4.3% of RA versus 5.4% of FA patients (P = 0.0131). Based on the Kidney Disease: Improving Global Outcomes criteria, patients with RA had threefold less AKI, and 0.68% of patients had stage 3 AKI versus 1.12% with FA (P = 0.0367). Post-intervention dialysis was necessary in 0.15% and 0.34%, respectively (P = 0.0814). • The risk for AKI was lower in ACS patients who underwent invasive management via RA compared with FA.

Abstract BACKGROUND It remains unclear whether radial access (RA), compared with femoral access (FA), mitigates the risk of acute kidney injury (AKI). OBJECTIVES The authors assessed the incidence of AKI in patients with acute coronary syndrome (ACS) enrolled in the MATRIX-Access (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of I t was in the arm where it all started for selective coronary angiography 50 years ago as performed by Dr Sones with a brachial artery cutdown. In the 1970s, Dr Judkins revolutionized the field by using a percutaneous femoral artery approach. Who would have thought that using a radial approach would ever be considered as new and innovative, and, even more, to be advocated as the preferred approach for cardiac catheterization. A lower risk of bleeding, earlier ambulation, and thus faster turn-around times are the advan- tages, which are very appealing to practice and business models of the twenty-first century as well. Known disadvantages include a higher radiation exposure for operators and patients, technical chal- lenges to the procedure, radial vasospasm, and radial artery occlusions. A reduction in the incidence of acute kidney injury (AKI) has been put on the balance, based on observational studies and their meta-anal- yses. No prospective, randomized trial had been done, but this became one of the three prespecified goals of the MATRIX COMMENT By Joerg Herrmann MD

Angiox) trial. METHODS Among 8,404 patients, 194 (2.3%) were excluded due to missing creatinine values, no or an incomplete coronary angiogram, or previous dialysis. The primary AKI-MATRIX endpoint was AKI, defined as an absolute (>0.5 mg/dl) or a rel- ative (>25%) increase in serum creatinine (sCr). RESULTS AKI occurred in 634 patients (15.4%) with

trial, AKI-MATRIX. The primary endpoint of this substudy was the incidence of AKI, as commonly defined by either an absolute (>0.5 mg/ dL) or a relative (>25%) increase in serum creatinine (sCr) from baseline during the hospitalization period. With this endpoint, a nearly 2% absolute and nearly 15% rela- tive reduction in the incidence of AKI with a radial approach in STEMI and NSTEMI patients was seen. There was no signifi- cant difference when the Kidney Disease: Improving Global Outcomes (KDIGO) cri- teria and stages were used. Furthermore, there was no significant difference in aver- age sCr levels and a significant but only a slightly more than 1- to 1.5-point difference in eGFR between the groups. This being said, requirements for dialysis were less in the radial group, especially in the anal- ysis excluding any cross-overs. Those at high risk for AKI, with preexisting reduc- tion of renal function, and with higher Killip classes seem to benefit the most from a radial approach for AKI prevention. Themechanismsas towhya radial approach

Dr Herrmann is Associate Professor of Medicine at Mayo Graduate School of Medicine in Minnesota.

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