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The slow rise in use of radial access for primary percutaneous coronary intervention (PCI) has clinicians arguing whether they should give transradial stenting extra spurs or let operators adopt it at their own pace.

"We believe that a much needed and readily achievable improvement in STEMI [ST-segment elevation MI] processes of care would be obtained through more widespread adoption of transradial, rather than transfemoral, access for primary PCI," wrote Robert Yeh, MD, MSc, of Beth Israel Deaconess Medical Center in Boston, and colleagues in a viewpoint published online in JAMA Cardiology.

Citing the RIVAL, RIFLE-STEACS, and MATRIX trials, Yeh's group suggested that a conservative 12% estimated relative survival improvement of transradial over transfemoral access would give a physician "as many as via the transradial approach before reaching the threshold at which performing the faster transfemoral procedure would be the preferred option."

"This extra time will not be required as operators gain additional experience with transradial procedures," they noted.

Operators have been overly focused on the the belief that it would lead to longer door-to-balloon times, Yeh and colleagues emphasized. "The widespread reduction in remains a remarkable achievement in STEMI treatment. But an overemphasis on this single quality measure has created unintended consequences for patients by impeding the adoption of other care processes perceived to be time sensitive."

They proposed a change to the door-to-balloon metric: a different time goal for each approach, with a more minutes allowed for the transradial approach.

"Allowing, for example, an additional 10 minutes for this approach is well within the acceptable delay indicated by a decision analysis based on the best available evidence," according to Yeh's group. "This proposal would mitigate the current perverse incentive for performing transfemoral primary PCI that is preventing many operators from using the transradial approach."

Yet H. Vernon Anderson, MD, of University of Texas Health Science Center in Houston, and David Faxon, MD, of Boston's Brigham and Women's Hospital, warned against such encouragement of transradial stenting.

"The real question facing us now is how to achieve the proper balance between radial artery and femoral artery access," they said in their own viewpoint article, noting drawbacks such as increased radiation exposure to both patients and operators when stents go in through the wrist.

Radial artery access is already slowly but surely making gains in the U.S., having gone from 2% of primary PCIs before 2009 to more than 20% in 2016, Anderson and Faxon noted.

"Incentives to shift the balance in one direction or the other would likely lead to unintended consequences, not the least of which may be manipulating (i.e., gaming) the system for a desired result," they concluded. "The radial artery access site for primary PCI may be preferred at times but can never become mandatory, and establishing incentives for this approach may prove counterproductive."