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What matters and what does not: Variations in STEMI PCI Techniques

Darwin’s theory of natural selection holds that random mutations will cause phenotypic variations. Most of them do not enhance survival. A few will. Those that enhance survival will tend to be propagated in the species and become prevalent. Variations in percutaneous coronary intervention (PCI) technique may work the same way. In the preceding article, Chiang et al. surveyed interventionists to identify variations in technique for PCI for ST-elevation myocardial infarction (STEMI). It identifies some variations that probably do not matter, and one that does. First, what “does not” matter? The survey showed that 97% or respondents rarely/never perform right heart catheterization before reperfusion and 95% rarely/never obtain central venous access as part of STEMI PCI. No surprises there. Aspiration thrombectomy is used routinely by 49% of respondents and selectively by 43%, consistent with a current IIa PCI guideline recommendation. Left ventriculography is performed routinely with STEMI PCI by 66% of respondents. No surprises there, either. The last finding that “does not” matter is that 19% of respondents image the culprit artery first and revascularize it immediately. The other respondents image all arteries, then do PCI. This controversy has prompted endless debates at our institution. The impatient culpritPCI-first camp argues that it yields the fastest door-toballoon times. They quote several studies that show their technique reduces door-to-balloon time by 10–15 min [1]. The more patient see-all-coronaries-first advocates argue that delaying door-to-balloon time by 10–15 min does not affect mortality [2] and may prevent PCI of nonculprit arteries while the real culprit remains closed. We argue that for a skilled interventionist mindful of the pitfalls of either approach, it matters little which strategy is used. Finally, what “does” matter? Chiang et al.’s survey found that only 17% of respondents prefer the radial approach for access for STEMI PCI. This is the variation that probably “does” matter, and is likely to survive natural selection and become prevalent. There is mounting evidence that radial access does make a difference for patients. A meta-analysis of randomized controlled trials of femoral versus radial access for STEMI PCI found a 45% decrease in mortality (P< 0.001) associated with radial access [3]. An analysis of the National Cardiovascular Data Registry (NCDR) data from 2007 to 2011 found a 24% reduction in mortality (P1⁄4 0.0455) associated with radial access [4]. Myriad studies have documented decreased bleeding and access site complications with radial access. Despite this, use of radial access for PCI STEMI has increased from just 0.9% in 2007 to 6.4% in 2011. The NCDR for fiscal year 2012–2013 reports 18% of all PCIs used radial access. Why does radial access remain neglected by so many? Skeptics have mustered arguments against radial access including inadequate evidence for its superiority, difficulty mounting the learning curve, higher cross-over rates, longer door-to-balloon times, higher radiation exposure, and greater technical difficulties with catheter placement and back-up [5]. We hold a different view. Interventionists at our institution have preferred radial access for both elective and STEMI PCI for the past several years. Yes, there was a learning curve, but we climbed it. In the past