CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 3, September – October 2024 164 AFRICA Similar to our study, some studies have reported no benefit of TRA on AKI. A study by Kolte et al. on patients with STEMI showed a non-significant change in the incidence of AKI, defined by > 0.5 mg/dl increase in SCr level, with TRA in the overall and PS-matched cohorts.13 A more recent study from Italy collected data from 4 199 patients undergoing angiography and/or PCI between 2007 to 2016, and concluded that TRA was not superior to TFA with regard to the development of AKI.14 The definition of AKI was the same as in our study, and AKI was observed at 13.2% in the radial and 11.7% in the femoral approach, which are similar to our results. The effect of TRA on AKI was found to be variable in previous studies. It appears that incidence of bleeding determined frequency of AKI more than TRA did. The protective effect of TRA on AKI appeared largely to be due to a reduction in bleeding events. Therefore, TRA should be preferred over TFA whenever possible. Exceptions include complex procedures that usually need larger catheters, which may not be suitable for TRA, a need for better guiding catheter support from the transfemoral route, and the presence of radial artery occlusion following previous transradial intervention. Numerous studies have shown that TRA reduces accesssite complications and bleeding events. The benefit is more pronounced in patients with ACS. Therefore, it is irrelevant whether TRA is associated with lower incidence of AKI after coronary intervention because of a reduction in bleeding episodes or atheroembolism from the aorta. It is also important to remember that the incidence of cholesterol embolism syndrome was reported as 0.15% in clinical studies and 25–30% in pathological series.18 Pathophysiologically, TRA probably reduces the incidence of cholesterol embolism to the renal arteries compared to the TFA, however, it seems the effect is small and difficult to differentiate from the effect of reduction in bleeding events. Limitations The relatively small sample size of the study is a limitation. In order to overcome the size issue, we analysed not only the conventional dichotomised AKI endpoint, but also absolute and relative changes in SCr level after PCI. They were very similar in both the overall and PS-matched patients. Another limitation of this study is its single centre and retrospective nature. Although we applied several statistical methods to reduce selection bias and to adjust for different variables in multivariate analysis, unknown or residual confounding factors could not be adjusted for. As a retrospective analysis based on hospital records, AKI was detected between two and seven days (median three days) after the intervention. A specific time point, instead of within seven days, would have been more accurate for the analysis. Echocardiographic data were not available for all patients, therefore an important predictor of AKI, left ventricular ejection fraction, was not evaluated and included in the regression analysis. The application of periprocedural hydration was not systematic. Although it was used in most patients, some patients received it only post-procedurally (STEMI patients), some received it both pre- and post-procedurally, and some elective patients may not have received any hydration at all. This might have affected the incidence of AKI, although it was valid for both radial and femoral patients. 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