angioseal versus radial approach in acute coronary syndrome

Conditions: Acute Coronary Syndrome

Summary: among non-st-segment elevation acute coronary syndrome patients submitted to early invasive strategy and randomized for the transfemoral or transradial approach, the angioseal vascular closure device would decrease the prevalence of vascular complications at puncture site, reaching the non-inferiority criterion when compared to the radial access.

antithrombotic therapy and percutaneous or surgical myocardial revascularization procedures are the basis of the treatment of patients admitted with non-st-segment elevation acute coronary syndrome. however, the desired reduction of the recurrence of ischemic events has as complication an increased incidence of bleeding. since arterial puncture followed by the insertion of an introducer has become the standard method to perform invasive cardiovascular procedures, complications related to vascular access have become an important bleeding site. among the strategies to decrease vascular complications, the transradial approach is a well stablished alternative to the transfemoral approach. for its part, vascular closure devices were introduced to decrease vascular complications, homeostasis time and ambulation time of patients submitted to invasive procedures by the transfemoral access. rapidly incorporated to the clinical practice, such devices to date have shown conflicting results with regard to their safety and efficacy. the inconsistency of data proving its safety limits its routine adoption as strategy to prevent vascular complications, requiring evidences through adequately designed randomized studies for this end.

Eligibility criteria:
inclusion criteria: * non-st-segment elevation acs patients \[ischemic symptoms suspicious of non-st-segment elevation acs (unstable angina or non-st-segment elevation ami) defined as clinical presentation compatible with a new manifestation of worsening of chest pain characteristic of ischemia, at rest or at minimum effort, lasting more than 10 minutes, and at least one of the following items: (a) ecg changes compatible with new ischemia (st segment depression of at least 1 mm, or transient st segment elevation, or st segment elevation ≤ 1 mm, or t wave inversion \> 2 mm in at least 2 contiguous shunts); (b) cardiac enzymes (ck-mb or troponin t or i) above the upper normality range limit; (c) patients \> 60 years of age without ecg or myocardial necrosis markers changes, however with previous documentation of coronary atherosclerotic disease (cad), confirmed by previous hospitalization due to ami, previous percutaneous or surgical myocardial revascularization procedure, significant cad confirmed by coronary angiography, or positive functional test for myocardial ischemia\]; * intention to submit patient to early invasive strategy consisting of coronary angiography immediately followed by pci, when applicable, in the first 72 hours after admission; * signed informed consent; * patient eligible for transradial and transfemoral coronary angiography and pci, being pre-requisites: (a) palpable radial artery with normal allen test or/and oximetry tests, (b) familiarity of the operator with the radial and femoral techniques using angioseal, (c) agreement of the operator to use the access route determined by the randomization process. exclusion criteria: * less than 18 years of age; * pregnancy; * chronic use of vitamin k antagonists or direct thrombin inhibitors, or oral xa-factor antagonists; * hypersensitivity to antiplatelet and/or anticoagulant drugs; * active bleeding or high bleeding risk (severe liver failure, active peptic ulcer, creatinine clearance \< 30 ml/min, platelets count \< 100.000 mm3); * uncontrolled systemic hypertension; * cardiogenic shock; * previous myocardial revascularization surgery with ≥ 1 internal mammary or radial artery graft; * documented chronic peripheral arterial disease preventing the use of the femoral technique; * severe concomitant disease with life expectancy below 12 months; * participation in drug or devices investigative clinical trials in the last 30 days; * indication of elective percutaneous coronary intervention to be performed in a moment different from immediately after coronary angiography; * medical, geographic or social conditions impairing the participation in the study or inability to understand and sign the informed consent term.

Keywords: transradial approach transfemoral approach vascular closure device