When did the preference for percutaneous coronary intervention (PCI) access sites shift from the femoral artery to the radial artery?

The Shift from Femoral to Radial Artery Access for PCI

The preference for percutaneous coronary intervention (PCI) access sites shifted from femoral to radial artery in the early 2010s, with major guidelines formally recommending radial access as the preferred approach by 2018-2021. 1

Timeline of the Transition

The transition from femoral to radial access occurred gradually over several years:

• Pre-2010: Femoral access was the dominant approach for PCI
• 2010-2015: Major clinical trials demonstrated benefits of radial access
• 2018: American Heart Association scientific statement formally endorsed radial access preference 1
• 2021-2022: ACC/AHA/SCAI guidelines solidified radial access as the recommended approach 1

Evidence Supporting the Shift

Key Clinical Trials That Drove the Change

Several landmark trials established the superiority of radial access:

• RIVAL trial (2011): Showed lower vascular complications with radial access
• RIFLE-STEACS trial (2012): Demonstrated lower cardiac mortality with radial access in STEMI patients
• MATRIX trial (2015): Found significantly lower rates of net adverse clinical events and mortality with radial access 1

Benefits of Radial Access

1. Reduced mortality: Particularly in ACS patients 1
2. Lower bleeding complications: Consistently demonstrated across multiple trials 1
3. Fewer vascular complications: 65% reduction compared to femoral access 1
4. Improved patient comfort: Earlier ambulation and discharge 1
5. Shorter hospital stays: Contributing to cost savings 1

Adoption Patterns and Learning Curve

The transition from femoral to radial access followed a predictable pattern:

• Initial adoption was slow due to learning curve challenges
• Centers transitioning to radial access showed complete adoption within approximately 5 years 2
• Fluoroscopy times and radiation doses were initially higher with radial access but equalized after operators gained experience 2
• By 2018, radial access had become the dominant approach in many centers

Current Guidelines

The 2021 ACC/AHA/SCAI Coronary Revascularization Guideline provides Class 1 recommendations for radial access:

1. For ACS patients: Radial approach is indicated to reduce death, vascular complications, and bleeding (Class 1, Level A) 1
2. For stable coronary disease: Radial approach is recommended to reduce access site bleeding and vascular complications (Class 1, Level A) 1

The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline reaffirms that "the radial artery has become the preferred vascular access site for patients undergoing cardiac catheterization and PCI." 1

Important Considerations and Caveats

• Operator experience: An important factor in successful radial procedures; guidelines note that operators should gain adequate experience 1
• Crossover rates: Higher in early adoption (7.6% vs. 2% for femoral) but decrease with operator experience 1
• Future CABG considerations: The decision to use radial access should consider the possibility that the radial artery may be needed for bypass grafting in the future 1
• Patient selection: Even in centers with high radial adoption (>90%), approximately 10% of patients still undergo femoral access due to complex clinical scenarios 3

Special Populations

Patients who still undergo femoral access in predominantly radial centers tend to have:

• Higher baseline bleeding risk
• More complex interventions
• Higher rates of shock, previous CABG, or chronic total occlusion interventions 3

These patients experience higher rates of complications, highlighting the importance of optimizing care when femoral access is necessary.