Why is this study important?

Radial access for coronary intervention is established as superior for reducing bleeding risk and is the preferred approach in most patients. In hopes of achieving the same benefits with peripheral intervention, radial-to-peripheral (R2P) has emerged as an alternative to common femoral artery (CFA) access. To date, there is minimal data comparing the two approaches.

What question was the study supposed to answer?

273 Consecutive R2P procedures were propensity-matched 1:1 to CFA cases from the multicenter, core laboratory-adjudicated XLPAD registry. The primary endpoint was 6-month major adverse limb events (MALE), a composite of all-cause mortality, target vessel revascularization (TVR), and major amputation, analyzed by a multivariable Cox proportional hazards model.

What did the study show?

Among a total of 546 patients (mean age 71±9 years; 32% women; 78% claudicants), nearly 50% of lesions were chronic total occlusions. Mean lesion lengths were longer in the CFA group (129 ± 92 mm vs 98 ± 92 mm; p<0.01). Stent (56%) and drug-coated balloon (29%) use were similar between groups. Technical success favored CFA (95% vs 87%) but remained clinically non-inferior (p=0.001; prespecified margin 15%). At 6 months, the R2P group had higher MALE (15.8% vs 8.1%; HR 1.99, 95% CI 1.19-3.35; p=0.006;), mainly driven by TVR (11.7% vs 5.1%; p=0.006), with similar rates of death (3.3%) and major amputation (1.1%).

Perspective

This trial is a significant advance in the R2P knowledge base. This is the largest real-world comparison to date. However, the results might be seen as disappointing. While technical success and periprocedural outcomes were non-inferior, both trended towards favoring CFA. The higher 6-month TVR is particularly concerning, as it is hard to imagine a scenario in which two procedures are better than one. Despite the outcome, the principal investigator (Sameh Sayfo, MD) should be commended for their effort. It is an area where we desperately need more data. Furthermore, it should be remembered that dedicated R2P equipment is still in the early stages of development. As technology advances, the outcomes may shift in favor of R2P.