Received: 26 December 2017 | Accepted: 27 December 2017

DOI: 10.1002/ccd.27490

ORIGINAL STUDIES

Adoption of the transradial approach for percutaneous coronary

intervention and rates of vascular complications following
transfemoral procedures: Insights from NCDR

Marwan Badri, MBChB1 | Timothy Shapiro, MD1 | Yongfei Wang, MS2,3 |

Karl E. Minges, PhD, MPH2,3 | Jeptha P. Curtis, MD2,3 | William A. Gray, MD1

1
Lankenau Heart Institute, Wynnewood,
Pennsylvania
Abstract
2
Center for Outcomes Research and Objectives: This study was designed to examine the association between adopting the transradial
Evaluation, Yale-New Haven Hospital, New
approach for percutaneous coronary intervention (PCI) and rates of vascular complications follow-
Haven, Connecticut
3
ing transfemoral PCI.
Section of Cardiovascular Medicine,
Department of Internal Medicine, Yale Background: Recent studies raised concerns that operators adopting the transradial approach may
University School of Medicine, New Haven,
lose their transfemoral access skills and experience increased rates of vascular complications.
Connecticut
Methods: Retrospective analysis of data from the NCDR CathPCI Registry to examine the rates of
Correspondence
vascular complications among physicians who were femoral operators (>90% of cases) in 2010–
Marwan Badri, MBChB, Lankenau Heart
Institute, 100 Lancaster Avenue, 2011 and later adopted the transradial approach to PCI among low-, intermediate-, or high-level
Wynnewood, PA 19096. adopters (33%, 34–66%, and >66%, respectively) in 2014–2015. Propensity score matching was
Email: marwanbadri@gmail.com used to control for confounding factors.

Funding information
American College of Cardiology
Foundation’s (ACCF) National
Cardiovascular Data Registry (NCDR)
Results: A total of 1,704,708 procedures performed by 4,697 operators were included. Most oper-
ators were low-level adopters (80.7%), followed by intermediate (15.7) and high-level adopters
(3.6%). Compared to the preadoption period, vascular complications of transfemoral PCIs following
transradial adoption increased among low-level adopters (1.29%–1.59%, adjusted OR [95% CI]:
1.24[1.20–1.28], P < 0.001), intermediate-level adopters (1.37%–1.92%, adjusted OR 1.40[1.29–
1.53], P < 0.001), and high-level adopters (1.54%–1.93%, adjusted OR 1.26[1.00–1.58], P 5 0.053).
In the post-adoption period, there was increase in access site bleeding that is likely due to change
in registry definition. There was no increase in hematomas, retroperitoneal bleeding or other vas-
cular complications.

Conclusions: Adoption of the transradial approach for PCI is not associated with clinically mean-
ingful increase in rates of vascular complications of transfemoral PCIs.

KEYWORDS
brachial, catheterization, complications, coronary artery disease, percutaneous coronary interven-
tion, radial, ulnar, vascular complications

1 | INTRODUCTION approach [1–3]. Current guidelines recommend considering transradial

The radial approach for cardiac catheterization and percutaneous coro-
nary intervention (PCI) is associated with a significant reduction in vas-
cular complications (access site bleeding, hematoma, pseudoaneurysm
formation, and retroperitoneal bleeding) compared to the femoral
access in patients undergoing PCI to reduce the risk of vascular compli-
cations [4–6]. Henceforth, there has been a steady increase in the
adoption rate of transradial catheterizations across the United States
[7]. However, recent single-center studies raised concern that physi-
cians who use radial access frequently may become less skilled in using

Catheter Cardiovasc Interv. 2018;1–7. wileyonlinelibrary.com/journal/ccd V

C 2018 Wiley Periodicals, Inc. | 1
2 | BADRI ET AL.

the femoral approach, resulting in higher rates of vascular complica-
tions [8,9]. Femoral access is needed in patients with anatomic arterial
variants that exist in 5% of patients and in patients with occluded radial
arteries [10,11]. Moreover, transradial PCI may not be feasible when a
procedure requires larger access than what can be accommodated by
the radial artery. Hence, competency in performing transfemoral PCI is
required by all interventional cardiologists. Accordingly, this study was
designed to test the hypothesis that increased adoption of the transra-
dial approach is associated with increased rates of vascular complica-
tions following transfemoral PCI.
2 | METHODS
period, along with procedures performed by operators with <20 PCIs
per year during the early or late periods. Finally, procedures by opera-
tors who did not perform PCI in both study periods were excluded.
The remaining 1,704,708 procedures were included in the analysis
(Figure 1)
2.3 | Study end points and definitions
The primary study end point was the occurrence of vascular complica-
tions following transfemoral PCI diagnosed within the same hospitaliza-
tion during or after the procedure. Vascular complications included
bleeding at access site, hematoma at access site, retroperitoneal bleed-
ing, and other vascular complications requiring treatment. Based on the

2.1 | Data source CathPCI registry definitions, in order for hematoma and retroperitoneal
bleeding to qualify as complications they needed to be associated with
The American College of Cardiology’s National Cardiovascular Data
either a hemoglobin drop of 3 g/dl, blood transfusion, or need for a
Registry (NCDR) CathPCI Registry is the largest cardiovascular data
surgical or endovascular intervention to treat the complication. In
registry in the United States, with over 85% of institutions performing
2012, the CathPCI registry definition of complications was modified so
PCI procedures electing to participate in the CathPCI Registry [12]. The
if any of the three parameters (hemoglobin drop 3 g/dl, transfusion,
CathPCI Registry prospectively collects data on patient characteristics
or intervention to treat a vascular complication) is documented without
and clinical features, including demographics, comorbid conditions, car-
a specific complication to explain them then that was considered an
diac status, coronary lesion, intracoronary device utilization, and
access-site bleeding event. Other vascular complications included
adverse event rates. Trained data abstractors use standardized defini-
access site occlusion, peripheral embolization, dissection, pseudoaneu-
tions to extract data, and quality checks are performed by the NCDR
rysm, and arteriovenous fistulas. The definitions of each of those com-
to ensure that over 95% completeness of specific data elements is
plications are available online [14]. A secondary analysis was performed
obtained, as described in greater detail elsewhere [12].
using the same components of the primary endpoint analysis but fol-
lowing all PCIs (transradial and transfemoral).
2.2 | Study data
Based on the availability of data in the CathPCI registry (versions 4.3.1 2.4 | Statistical analysis
and 4.4), data for the early period were obtained from 2010 to 2011
Baseline demographic, clinical, and procedural characteristics were
and data for the late period were obtained from 2014 to 2015. To
examined overall and compared between the early and late periods
examine the impact of transradial adoption on femoral operators, the
using the Chi-square test for categorical variables and t tests for con-
operators included in the early period had to have performed more
tinuous variables. Counts and percentages were used to present cate-
than 90% of their annual procedures in the early period through the
gorical variables and means with standard deviations were used to
femoral approach. We then stratified operators into three groups based
on the percentage of the transradial PCIs they performed in the late
period (postradial adoption): low-level transradial adopters (33%),
intermediate-level transradial adopters (34%–66%), and high-level
transradial adopters (>66%). To examine the association of adopting
the transradial approach to PCI with vascular complications of transfe-
moral and all (transradial and transfemoral) PCIs, we compared the
rates of vascular complications in each of these three groups with the
rates of complications of procedures performed by the same operators
in the early (preadoption) period. We used National Provider Identifiers
(NPI) to link physicians between the two time periods.
Out of 2,710,698 PCIs available for analysis, we excluded proce-
dures in which access site was neither transradial nor transfemoral. We
also excluded procedures in which mechanical support was used
(including intra-aortic balloon pump) as these procedures are associated
with higher rates of complications [13]. Procedures for which no opera-
tor NPI was available were also excluded. Then we excluded proce-
dures performed by operators with <90% transfemoral PCI in the early FIGURE 1 Study procedure selection flowchart
BADRI ET AL. | 3

T AB LE 1 Baseline demographic, clinical, and procedural characteristics

Early period Late period

All procedures (2010–2011) (2014–2015) P value

Number of procedures 1,704,708 873,145 831,563 <0.001

Age 64.97 (11.99) 64.72 (12.06) 65.23 (11.92) <0.001

Women 545,431 (32.00) 285,351 (32.68) 260,080 (31.28) <0.001

Race <0.001
White 1,495,041 (87.70) 769,955 (88.18) 725,086 (87.20)
Black 143,003 (8.39) 71,609 (8.20) 71,394 (8.59)
Other 66,664 (3.91) 31,581 (3.62) 35,083 (4.22)

Hypertension 1,407,674 (82.58) 718,158 (82.25) 689,516 (82.92) <0.001

Diabetes <0.001
Noninsulin treated 359,883 (21.11) 185,916 (21.29) 173,967 (20.92)
Insulin treated 246,791 (14.48) 116,860 (13.38) 129,931 (15.62)

Dyslipidemia 1,349,195 (79.15) 699,740 (80.14) 649,455 (78.10) <0.001

Smoker 458,265 (26.88) 239,477 (27.43) 218,788 (26.31) <0.001

ESRD on dialysis 42,393 (2.49) 20,649 (2.36) 21,744 (2.61) <0.001

Cerebrovascular disease 215,682 (12.65) 107,128 (12.27) 108,554 (13.05) <0.001

Peripheral arterial disease 208,910 (12.25) 107,899 (12.36) 101,011 (12.15) <0.001

Prior MI 514,159 (30.16) 260,780 (29.87) 253,379 (30.47) <0.001

Prior PCI 707,757 (41.52) 359,838 (41.21) 347,919 (41.84) <0.001

Prior CABG 314,920 (18.47) 163,655 (18.74) 151,265 (18.19) <0.001

CAD presentation <0.001

No symptoms 120,568 (7.07) 80,684 (9.24) 39,884 (4.80)
Symptoms unlikely ischemic 41,496 (2.43) 25,426 (2.91) 16,070 (1.93)
Stable angina 250,581 (14.97) 149,725 (17.15) 100,856 (12.13)
Unstable angina 679,969 (39.89) 335,368 (38.41) 344,601 (41.44)
NSTEMI 349,995 (20.53) 155,873 (17.85) 194,122 (23.34)
STEMI 262,099 (15.38) 126,069 (14.44) 136,030 (16.36)

Underwent thrombolysis 14,457 (0.85) 8,904 (1.02) 5,553 (0.67) <0.001

Cardiogenic shock within 24 h 18,858 (1.11) 8,427 (0.97) 10,431 (1.25) <0.001

Cardiac arrest within 24 h 25,824 (1.51) 11,838 (1.36) 13,986 (1.68) <0.001

Access site <0.001

Transfemoral 1,545,313 (90.65) 861,565 (98.67) 683,748 (82.22)
Transradial 159,395 (9.35) 11,580 (1.33) 147,815 (17.78)

Pre-PCI laboratory values <0.001

Hemoglobin 13.53 (1.95) 13.54 (1.91) 13.52 (1.98)
Creatinine 1.19 (1.03) 1.19 (0.99) 1.19 (1.06)

Procedure medications <0.001

Aspirin 1,501,568 (88.08) 765,818 (87.71) 735,750 (88.48)
P2Y12 inhibitors 1,515,983 (88.93) 763,390 (87.43) 752,593 (90.50)
Anticoagulants 1,012,544 (59.40) 482,460 (55.26) 530,084 (63.75)
Direct thrombin inhibitors 990,328 (58.09) 517,196 (59.23) 473,132 (56.90)
GP IIb/IIIa inhibitors 393,466 (23.08) 240,945 (27.60) 152,521 (18.34)
In-hospital mortality 16,307 (0.96) 7,273 (0.83) 9,034 (1.09) <0.001

present continuous variables. To balance the patients’ characteristics
for the comparison of vascular complications, we first performed a
logistic regression model with an indicator of post period (1 5 late
period and 0 5 early period) as dependent variables to generate the
propensity scores for each procedure and then matched a procedure in
the early period and a procedure in the late period for each physician
in the same type of access site (femoral or radial). The variables
included in the model were age, female sex, black race, other race, prior
MI, prior heart failure, prior valve surgery, non-insulin-treated diabetes,
insulin-treated diabetes, dialysis, cerebrovascular disease, peripheral
4 | BADRI ET AL.

T AB LE 2 Vascular complications following transfemoral PCIs in the early and late periods

Vascular complications following transfemoral PCI procedures

Unadjusted Adjusted
Early period Late period
(2010–2011) (2014–2015) Unadjusted Adjusted OR Adjusted
preadoption postadoption P value (95% CI) P value

Complications all operators

Total 6,760 (1.30) 8,505 (1.64) <0.001 1.26 (1.22–1.30) <0.001
Access site bleeding 2,247 (0.43) 4,434 (0.85) <0.001
Access site hematoma 3,709 (0.71) 3,251 (0.63) <0.001
Retroperitoneal bleeding 946 (0.18) 958 (0.18) 0.78
Other vascular complications 2,167 (0.42) 2,153 (0.41) 0.83

Complications among low-level

(33%) transradial adopters
Total 5,688 (1.29) 7,028 (1.59) <0.001 1.23 (1.20–1.28) <0.001
Access site bleeding 1,896 (0.43) 3,661 (0.83) <0.001
Access site hematoma 3,129 (0.71) 2,681 (0.61) <0.001
Retroperitoneal bleeding 792 (0.18) 775 (0.18) 0.66
Other vascular complications 1,820 (0.41) 1,806 (0.41) 0.81

Complications among intermediate-level

(34%–66%) transradial adopters
Total 941 (1.37) 1,313 (1.92) <0.001 1.40 (1.29–1.53) <0.001
Access site bleeding 306 (0.45) 692 (1.01) <0.001
Access site hematoma 512 (0.75) 512 (0.75) 0.93
Retroperitoneal bleeding 139 (0.20) 161 (0.24) 0.20
Other vascular complications 298 (0.44) 306 (0.45) 0.74

Complications among high-level

(>66%) transradial adopters
Total 131 1.54) 164 (1.93) 0.051 1.25 (1.00–1.58) 0.053
Access site bleeding 45 (0.53) 81 (0.95) 0.001
Access site hematoma 68 (0.80) 55 (0.65) 0.24
Retroperitoneal bleeding 15 (0.18) 22 (0.26) 0.25
Other vascular complications 49 (0.58) 41 (0.48) 0.39

arterial disease, chronic lung disease, hypertension, smoking, dyslipide-
mia, family history of premature CAD, prior PCI, prior CABG, thrombo-
lytics, heart failure within 2 weeks, cardiogenic shock within 24 h,
cardiac arrest within 24 h, CAD presentation (symptoms unlikely ische-
mic, stable angina, unstable angina, NSTEMI, STEMI), undergoing other
procedures, catheterization status (elective, urgent, emergent), PCI sta-
tus (urgent, emergent, salvage), cardiogenic shock at the start of PCI,
PCI for high-risk NSTEMI or unstable angina, and procedure medica-
tions (aspirin, P2Y12 inhibitors, anticoagulants, direct thrombin inhibi-
tors, and GP IIb/IIIa inhibitors). With the matched procedures, we then
compared the vascular complications between early and late period for
each of the three groups using the McNemar’s test for the matched
pairs and conditional logistic regression to examine the effect of the
late versus early period on vascular complications. Numbers and per-
centage of the vascular complications among the matched pairs and
the odds ratio for post period versus the early period were reported.
3 | RESULTS
A total of 1,704,708 PCI procedures were performed across the two
study periods (early period: 873,145; late period: 831,563). The mean
age of patients was 65.0 years and 32.0% of patients were women.
Most patients were hypertensive (82.6%) and dyslipidemic (79.1%).
Compared to patients undergoing PCI in the early period, those treated
in the late period were older and more likely to have prior myocardial
infarction, end-stage renal disease on dialysis, cardiogenic shock, and
cardiac arrest within 24 h of the procedure (P < 0.01). In addition,
higher proportions of patients in the late period presented with acute
myocardial infarction (both ST elevation and non-ST elevation) and
lower proportions presented with stable coronary syndromes. The
remaining baseline demographic, clinical, and procedural characteristics
of patients undergoing the procedures are listed in Table 1.
The proportion of PCIs performed using the transradial approach
increased from 1.3% in the early period to 17.8% in the late period.
Among 4697 operators who were primarily femoral operators (>90%
of PCIs) in the 2010–2011 early period, the majority 3790 (80.7%)
remained low-level adopters in the late (2014–2015) period, whereas
738 (15.7%) were intermediate-level adopters and 169 (3.6%) were
high-level adopters.
Among patients matched by operator and access site, the primary
endpoint of access-site related vascular complications following trans-
femoral PCIs performed by all operators increased from 1.30%
to 1.64% (adjusted OR [95% CI]: 1.26 [1.22–1.30], P < 0.001). Findings
were similar across groups stratified by physician adoption of
BADRI ET AL. | 5

T AB LE 3 scular complications following all PCIs in the early and late periods

Vascular complications following all PCI procedures

Unadjusted Adjusted
Early period Late period
(2010–2011) (2014–2015) Unadjusted Adjusted OR Adjusted
preadoption postadoption P value (95% CI) P value

Complications among all operators

Total 6,794 (1.29) 8,543 (1.62) <0.001 1.26 (1.22–1.30) <0.001
Access site bleeding 2,258 (0.43) 4,460 (0.85) <0.001
Access site hematoma 3,725 (0.71) 3,261 (0.62) <0.001
Retroperitoneal bleeding 948 (0.18) 959 (0.18) 0.80
Other vascular complications 2,180 (0.41) 2,162 (0.41) 0.78

Complications among low-level (33%) transradial adopters

Total 5,703 (1.28) 7,054 (1.58) <0.001 1.24 (1.20–1.29) <0.001
Access site bleeding 1,900 (0.43) 3,678 (0.82) <0.001
Access site hematoma 3,137 (0.70) 2,689 (0.60) <0.001
Retroperitoneal bleeding 793 (0.18) 775 (0.17) 0.64
Other vascular complications 1,826 (0.41) 1,812 (0.41) 0.81

Complications among intermediate-level (34%–66%)

transradial adopters
Total 957 (1.33) 1,322 (1.84) <0.001 1.39 (1.28–1.51) <0.001
Access site bleeding 311 (0.43) 698 (0.97) <0.001
Access site hematoma 519 (0.72) 517 (0.72) 0.95
Retroperitoneal bleeding 139 (0.19) 161 (0.22) 0.20
Other vascular complications 305 (0.42) 308 (0.43) 0.90

Complications among high-level (>66%) transradial adopters 134 (1.41) 167 (1.76) 0.05 1.25 (0.99–1.57) 0.055
Total 47 (0.50) 84 (0.89) 0.001
Access site bleeding 69 (0.73) 55 (0.58) 0.20
Access site hematoma 16 (0.17) 23 (0.24) 0.26
Retroperitoneal bleeding 49 (0.52) 42 (0.44) 0.46
Other vascular complications

transradial PCI. Among low-level adopters, occurrence of the primary 4 | DISCUSSION

endpoint increased from 1.29% to 1.59% (adjusted OR [95% CI]: 1.24
[1.20–1.28], P < 0.001). Similarly, complication rates following PCIs by
intermediate-level adopters increased from 1.37% to 1.92% (adjusted
OR [95% CI]: 1.40 [1.29–1.53], P < 0.001). Vascular complication rates
also increased among high-level adopters from 1.54% to 1.93%; how-
ever, this increase was not statistically significant (adjusted OR [95%
CI]: 1.26 [1.00–1.58], P 5 0.053).
Findings were similar in the secondary analysis of the all PCI
cohorts (transfemoral and transradial PCIs). In this cohort, the rate of
access-related vascular complications increased among low-level
adopters from 1.28% to 1.58% (adjusted OR [95% CI]: 1.24 [1.20–
1.29], P < 0.001) and for intermediate-level adopters from 1.33% to
1.84% (adjusted OR [95% CI]: 1.39 [1.28–1.51], P < 0.001). Transfe-
moral PCI performed by high-level transradial adopters was also associ-
ated with increased rates of access site complications in the late
compared to the early period (1.41% vs 1.76%). Similar to the
transfemoral-only cohort, this increase did not reach statistical signifi-
cance (adjusted OR [95% CI]: 1.25 [0.99–1.57], P 5 0.056) (Table 3).
The rates of access site bleeding increased in the late compared to
the early period both in the transfemoral (0.43%–0.85%, P < 0.001)
and the all PCIs cohorts (0.43%–0.85%, P < 0.001). There was no
increase in access site hematoma, retroperitoneal bleeding or in other
vascular complications (Tables 2 and 3).
This study showed that rates of vascular complications following trans-
femoral PCI performed by physicians who adopted the transradial
approach in variable proportions of their PCIs were similar to preadop-
tion levels. There was a small, clinically insignificant increase in transfe-
moral vascular complications performed by low-, intermediate-, and
high-level adopters of transradial PCI. This increase was only seen in
access site bleeding with no increase in the rates of hematomas, retroper-
itoneal bleeding, or other vascular complications. Unlike in the low and
intermediate level of transradial adopters, the increase in rates of vascular
complications seen among high-level adopters was not statistically signifi-
cant. This may be explained by the smaller number of physicians in the
high-level adoption group compared to the two other groups.
The increase of vascular complications in the overall group of
physicians may be related to two factors. First, to capture more bleed-
ing events and better reflect clinical practice, in 2012, NCDR assigned
an access-site bleeding event to patients who have hemoglobin drop of
3 g/dl, required blood transfusion or underwent an intervention to
treat bleeding when another cause of bleeding is not documented. This
likely explains most of the increase in access-site bleeding events seen
in all groups between the two study periods. Second, the population of
patients undergoing PCI in the United States is in general older and has
more comorbidities than in the past [15]. This can be observed in this
6 |
study with higher rates of patients with acute coronary syndromes, car-
diogenic shock, cardiac arrest, and end-stage renal disease in the late
compared to the early period. Although these factors were controlled
for and included in the logistic regression model, there may be unmeas-
ured factors that increase the risk of periprocedural bleeding that likely
coexist in the same group of high-risk patients.
Several studies have demonstrated a significant reduction of
access-site vascular complications when PCI is performed through the
transradial approach [16,17]. In many studies this reduction in compli-
cations was associated with reduced adverse events including mortality
[2,3]. Transradial PCI also offers significant cost savings related to
reduction in the rates of complications, shorter lengths of stay and
reduced nursing workload [18,19]. Nevertheless, the skills required to
perform emergent and nonemergent transfemoral procedures remain
essential for all interventional cardiologists. Hence, the potential adverse
impact of adopting the transradial approach on femoral skills seen in
two single-center studies would have significant implications for both
practicing interventionists and fellows in training [8,9]. The lack of asso-
ciation we observed between operators’ adoption of transradial PCI and
clinically significant femoral complications despite an increasingly com-
plex patient population seen in our study is therefore reassuring. Fur-
thermore, a recent large study showed no correlation at the institutional
level between adoption of the transradial approach at PCI centers and
vascular complications following transfemoral procedures [20]. The find-
ings of these two large studies, therefore, encourage the continued
adoption of the transradial route as the default approach to PCI.
While this study is the largest analysis to examine the correlation
between transradial adoption and vascular complications, it has several
limitations. First it is a retrospective analysis and therefore its findings
are subject to the effects of unmeasured confounders despite adjust-
ment for a large number of covariates. Second, the femoral skills of
interventionists adopting the transradial approach may be maintained
by performing peripheral vascular procedures or structural heart dis-
ease procedures not measured in this study. Third, this analysis does
not account for physicians’ procedural volume, experience, or certifica-
tion at the time of adoption of the transradial approach; it is possible
that less experienced operators including newly graduating interventional
cardiologists with predominantly radial training would have higher rates
of femoral complications. Fourth, these results may not remain the same
if the time between the two study periods was longer than two years,
which may lead to more loss of femoral skills. Finally, the high-level
adopters group is only represented by a small number of operators, which
limits the study’s power to detect the impact of radial adoption on femo-
ral complications in this group.
5 | CONCLUSIONS
This study showed that apart from a registry definition-related increase
in access site bleeding, adopting the transradial approach as the default
access site for PCI is not associated with clinically meaningful increase
in access-site-related complications following transfemoral PCI. The
transradial approach to PCI may allow physicians to perform coronary
BADRI ET AL.
interventions on an increasingly complex patient population without
significant increase in access-site related complications.
ACKNOWLE DGME NT
This study was supported by the American College of Cardiology
Foundation’s (ACCF) National Cardiovascular Data Registry (NCDR).
DISC LOSUR E
Drs Minges and Curtis receive salary support under contract with the
National Cardiovascular Data Registry to provide analytic services. Dr
Curtis has ownership interest in Medtronic. There were no other dis-
closures to report.
ORC ID
Marwan Badri MBChB http://orcid.org/0000-0003-0159-6670
Jeptha P. Curtis MD http://orcid.org/0000-0002-6872-0501
William A. Gray MD http://orcid.org/0000-0003-4676-2839
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How to cite this article: Badri M, Shapiro T, Wang Y, Minges
KE, Curtis JP, Gray WA. Adoption of the transradial approach
for percutaneous coronary intervention and rates of vascular
complications following transfemoral procedures: Insights from
NCDR. Catheter Cardiovasc Interv. 2018;00:1–7. https://doi.
org/10.1002/ccd.27490