Research report: Vascular Access Site, Frailty and Outcomes in Older Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes

To determine whether the procedural safety profile of transradial catheterization remains intact among clinically compromised seniors, investigators conducted a retrospective cohort study examining post-procedure outcomes across distinct frailty profiles. Published in the medical journal Cardiology and Therapy, the investigation systematically compared outcomes between transfemoral and transradial vascular access pathways in older patients undergoing percutaneous coronary intervention. By evaluating consecutive older patients across predefined diagnostic strata, the clinical research team clarified the distinct contributions of mechanical entry routes and systemic physiological reserves toward early periprocedural complications and one-year survival trajectories.

The study protocol evaluated 227 consecutive older patients aged 70 years and older who were treated with percutaneous coronary intervention for acute coronary syndromes at Leiden University Medical Center between January 2014 and June 2016. In the overall cohort, the mean age was 79.0 ± 6.1 years, comprising 133 men representing 58.6 percent of the sample and 94 women representing 41.4 percent. The presenting diagnoses encompassed ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and unstable angina treated under contemporary European Society of Cardiology guidelines. Across the analyzed patient collective, the treating interventional cardiologists utilized a femoral arterial entry route in 122 patients, representing 53.7 percent of the cohort, while opting for a radial arterial route in 105 patients, accounting for 46.3 percent. In addition, departmental protocol mandated femoral catheterization for all patients with a history of prior coronary artery bypass grafting to optimize arterial and venous graft visualization.

Upon initial hospital admission, geriatric vulnerability was systematically screened by nursing personnel utilizing the standardized Dutch safety management system, known natively as the Veiligheidsmanagementsysteem screening instrument. This protocolized bedside tool assesses four discrete domains linked to progressive functional decline, evaluating independence in activities of daily living, history of recent falls, systemic undernutrition, and risk factors for acute inpatient delirium. Functional status was specifically recorded using the six-item Katz Index of Independence in Activities of Daily Living, which systematically monitors whether bedside physical assistance is required for bathing, dressing, toileting, transferring, eating, and continence. The composite screening metric sums positive risk indicators across the designated domains to generate a score ranging between zero and 15 points, with a baseline threshold of one or more points designating clinical frailty. Among the 222 enrolled individuals with documented admission screening records, 78 patients, or 35.1 percent of the evaluable cohort, met the formal criteria for frailty, displaying significant associations with advanced chronological age, female sex, diabetes mellitus, lower left ventricular ejection fraction, prior cerebrovascular accidents, and frequent multivessel revascularization.

The primary clinical outcomes of the investigation were defined as all-cause mortality measured at one year alongside a composite 30-day early endpoint combining all-cause mortality, access site vascular complications, bleeding events, recurrent myocardial infarction, and stroke. Secondary endpoints tracked these individual clinical components alongside total inpatient length of stay. Vascular complications encompassed major access site hemorrhages, retroperitoneal bleeding, hematomas measuring greater than five centimeters in diameter, compartment syndrome, pseudoaneurysm formation, arteriovenous fistulas, limb ischemia, and surgical vascular repairs. Bleeding episodes were categorized in accordance with standardized criteria from the landmark RIVAL clinical trial to ensure methodological comparability. Documented follow-up data showed that procedural access site crossovers occurred in six patients, representing 2.6 percent of the overall study collective, with all transitions occurring among patients initially assigned to attempted transradial catheterization. In contrast, cardiovascular risk factors including systemic hypertension, diabetes, and active smoking status were balanced across access site groups, alongside uniform utilization patterns for antithrombotic medications, oral anticoagulants, and glycoprotein IIb/IIIa inhibitors.

Analysis of early clinical outcomes demonstrated marked differences between the vascular access sites within the first month following intervention. The primary 30-day composite endpoint developed in 18.9 percent of patients treated via the femoral route, totaling 23 individuals, compared to 3.8 percent of patients treated through radial access, representing four individuals. This disparity yielded an unadjusted odds ratio of 0.17 with a 95 percent confidence interval ranging from 0.06 to 0.51, maintaining statistical significance after adjusting for biological sex and presentation with Killip class three or four heart failure, which produced an adjusted odds ratio of 0.18. This clinical divergence was primarily driven by major and minor bleeding episodes, which occurred in 11.5 percent of femoral access cases and zero percent of radial access cases, representing nine major and four minor bleeding events. Access site vascular complications developed in 8.5 percent of the femoral cohort versus 2.0 percent of the radial cohort, while 30-day mortality occurred in 8.2 percent versus 1.0 percent, respectively. Stroke and recurrent ischemic infarctions remained infrequent and exhibited no significant variation between access groups.

To establish whether systemic physiological frailty altered the comparative performance of radial arterial entry, the investigators examined interaction models stratified by admission screening scores. Among patients classified as frail, the 30-day composite complication endpoint occurred in 20.5 percent of femoral access cases compared with 5.9 percent of radial access cases. In the non-frail cohort, the composite complication endpoint developed in 17.9 percent of femoral cases compared with 3.0 percent of radial interventions, demonstrating an absolute reduction of approximately 15 percentage points in both patient strata. Logistic regression yielded an odds ratio for radial access of 0.24 among frail patients and 0.14 among non-frail individuals, with a calculated ratio of odds ratios of 1.70, a 95 percent confidence interval spanning 0.19 to 15.54, and an interaction p-value of 0.64. For one-year mortality, the ratio of odds ratios was 1.24 with an interaction p-value of 0.82, while proportional hazards modeling indicated a hazard ratio ratio of 1.15 with an interaction p-value of 0.88. Consequently, the study identified no statistically significant evidence of effect modification between baseline frailty status and vascular access choice.

Beyond procedural entry mechanics, systemic frailty displayed significant associations with extended hospital admissions and long-term survival trajectories. Patients meeting admission frailty criteria experienced longer hospital stays, remaining admitted for an average of 1.61 additional days compared to non-frail counterparts after multivariable adjustment for vascular access site. One-year overall mortality reached 15.4 percent in the frail patient group compared to 6.9 percent among patients without frailty, producing an unadjusted one-year survival rate of 84.6 percent versus 93.1 percent. In survival modeling adjusted solely for procedural access site, frailty was associated with heightened one-year all-cause mortality, showing a hazard ratio of 2.35 with a 95 percent confidence interval from 1.01 to 5.43. However, upon introducing additional adjustment for chronological age into the proportional hazards model, this statistical association attenuated to a hazard ratio of 1.56 with a wide confidence interval crossing unity from 0.64 to 3.76, indicating that chronological age explained much of the observed univariable survival difference. Notably, frailty was not associated with an increased incidence of 30-day composite complications or acute post-procedural bleeding.

The study authors highlighted several methodological limitations that contextualize the clinical interpretation of the findings. As a single-center retrospective observational study of 227 patients conducted between 2014 and 2016, the analysis drew from historical practices that preceded current widespread default radial adoption, precluding direct causal conclusions. Because interventional operators selected the access site based on patient presentation and technical criteria—directing all prior bypass graft patients to femoral access—confounding by indication could not be completely excluded. Furthermore, with 22 total deaths and 27 composite events, the study possessed limited statistical power for extensive multivariable adjustment and interaction testing. The resulting wide confidence intervals around the interaction estimates remain compatible with either a substantially larger or a substantially smaller relative benefit for radial access in frail seniors. Additionally, unmeasured clinical severity factors, including cardiac arrest presentations, and lack of cause-specific adjudication for cardiac versus non-cardiac deaths restricted granular competing risk evaluations. Complete case analyses were applied across variables, noting that five patients lacked admission frailty scores and 51 lacked exact discharge duration tracking.

In their concluding synthesis, the researchers underscored that transradial access in patients aged 70 years and older undergoing percutaneous coronary intervention for acute coronary syndromes correlates with markedly fewer early vascular complications and bleeding episodes, mirroring evidence from large randomized trials in general populations. Meanwhile, admission frailty screening reliably identified vulnerable individuals prone to protracted hospitalization and diminished one-year survival, an adverse prognostic trajectory largely attributable to advanced age rather than early procedural complications. Nevertheless, given the observational nature and sample size constraints of the interaction analyses, the authors emphasized that these findings must be considered hypothesis-generating, warranting confirmation in prospective randomized investigations designed to optimize revascularization strategies and shared clinical decision-making for vulnerable older adults.

Subject of Research: Vascular access site selection and frailty assessment in older patients undergoing percutaneous coronary intervention

Article Title: Vascular Access Site, Frailty and Outcomes in Older Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes

Article References: Karalis, I., Andreou, C., Mouratidou, M., & Jukema, J. W. (2026). Vascular Access Site, Frailty and Outcomes in Older Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes. Cardiology and Therapy. https://doi.org/10.1007/s40119-026-00486-0

Image Credits: AI Generated

DOI: 10.1007/s40119-026-00486-0

Keywords: Cardiology, Percutaneous Coronary Intervention, Acute Coronary Syndrome, Vascular Access, Radial Access, Femoral Access, Geriatric Cardiology, Clinical Frailty, Vascular, Access, Site, Frailty