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Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29 Page 7 of 17

3.7% vs. 1.5% (P = 0.58). One-year follow-up myocardial infarction occurred in 1.9% and 1.5% (P = 1.00) in
octogenarians and younger patients, respectively. Interestingly, some complications occurred less frequently
with the octogenarian group than its younger counterpart such as in-hospital subacute stent thrombosis and
1-year follow-up cerebrovascular accidents, 0% vs. 1.5% (P = 1.00) and 1.9% vs. 2.3% (P = 1.00), respectively.
Although recent studies have also shown some variations in their results, in 2017 many papers have reported
relatively high PCI success rates in the elderly that ranged approximately from 75% to 95% [55-57] . Many of
these recent papers have reported better mortality and some complications trends than before [42,55,58,59] .
Some of them even reported similar rates of major adverse events in both young adults and elderly in more
critical situations such as patients with atrial fibrillation (A-fib) undergoing PCI. Lahtela et al. conducted
[60]
a post-hoc analysis of 925 A-fib patients’ data from the atrial fibrillation undergoing coronary artery stenting
(AFCAS) registry and showed comparable incidence of in-hospital and 1-month major adverse cardiac and
cerebrovascular events (MACCE) in octogenarian patients and younger ones . It is worth mentioning that
[61]
some recent studies still demonstrate a quit high adverse outcomes rates including in-hospital mortality that
reached up to 20% [62,63] .

PROCEDURAL ASPECTS IN ELDERLY
Many aspects regarding PCI procedure in the elderly can be modified, adjusted, and tailored in order to
make this very segment of the population more suitable for such a procedure and to render the interventional
cardiologists more comfortable to decide to perform these procedures in older patients. Among these aspects
are the length of procedure, the volume of contrast agent, the access site, the nature of the intervention, the
type of the stent, and the length of hospital stay.

ACCESS SITE
Generally, transfemoral approach has been the traditional standard of care for many years, however,
previous studies have shown that the newer transradial route is superior to the transfemoral one as the
former has been associated with better results and lower rates of complications and it has been increasingly
used instead of the femoral access in the general population [64,65] . In terms of the use of this approach in the
elderly undergoing PCI, the net benefit is still not totally clear. The differences between both approaches in
older patients have been reported in some studies and they demonstrated a high percentage of old patients’
PCI in whom transradial approaches have been performed. The transradial access has been used in up to
almost 80% of old aged patients of some cohorts [66,67] . In a 1:1 propensity score analysis of data from 1098
patients aged 75 years and older who underwent PCI with either transfemoral or transradial approach,
lower rates of in-hospital and 1-year follow-up major adverse clinical events, in-hospital MI, access site
complications, and major bleeding were associated with the use of transfemoral access . Other adverse
[66]
clinical outcomes occurred less frequently with the transradial approach such as in-hospital death and
target vessel revascularization but there were no significant statistical differences between the two groups.
The same study demonstrated comparable rates of non-access site related major bleeding events with both
approaches . In contrary, some recent studies have also shown a very low usage of the transradial approach
[66]
with the elderly. Among 1945 octogenarian patients of the Korea Acute Myocardial Infarction Registry,
1609 participants (82.7%) underwent PCI using the transfemoral approach and only 336 (17.3%) with the
transradial approach. Nevertheless, using the transradial access has been found to be a predictor of a lower
in-hospital mortality in the same group of patients . In the same study, intra-aortic balloon pump (IABP)
[68]
had to be used in 103 (6.4%) patients in the transfemoral group vs. only 5 (1.5%) patients of the transradial
group. Access site can also affect other variables like the time and volume of the contrast agent and the
length of hospital stay, as the transradial approach was shown to be associated with a shorter hospital
stay and a lower dose of contrast dye comparing to transfemoral one among older patients . However,
[67]
several other studies showed comparable contrast volume and procedure time with both approaches [41,66] .
In terms of procedural success, several studies demonstrated almost similar PCI success in elderly using