January 21st, 2011
To Arms! Or, Maybe Not?
Richard A. Lange, MD, MBA and L. David Hillis, MD
According to a recently published opinion piece in a British cardiology journal, enthusiasm for the transradial approach over the femoral approach in primary PCI is not justified.
The authors cite numerous problems with the radial approach compared with the femoral approach (i.e., up to a 10% crossover rate, prolonged procedure time, increased radiation exposure for the patient and physician) and a lack of compelling evidence that it reduces major adverse cardiac and cerebrovascular events in the setting of primary PCI. In conclusion, our colleagues from the other side of the pond — while acknowledging that radial access does offer clear benefit for purely diagnostic angiography and elective PCI — encourage us to keep a leg up (so to speak) when considering the radial approach for primary PCI.
Is the radial approach for primary PCI a passing fad…and likely to suffer the same fate as atherectomy and polyester leisure suits?
Do you perform primary PCI via the radial approach? If so, how often?
5 Responses to “To Arms! Or, Maybe Not?”
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I’ve been a default radialist for over 10 years and several of our IC’s, including myself have adopted this strategy for primary PCI as well as electives here at St. Joe’s in Atlanta. If there is a patient population that deserves the radial approach more than others, I feel it’s the primary PCI population, given their increased bleeding risk. We have not found higher DTB times among our radialists compared to femoralists at our institution. We have, however, seen ZERO bleeding complications among primary PCI patients intervened on via the radial approach over a 2 year period. The rescue-PCI patient, and we still get them, is certainly the one we feel should be targeted the most for radial given a higher baseline bleeding profile.
There are certainly others locally who have not made the “call to arms” as you have described, primarly with the same concerns you have listed. My general feeling though is that they are mostly reluctant to spend the time needed to learn a new approach while in busy private practices.
The radiation issue has always been a concern despite several publications to suggest that it’s not too much of a difference among dedicated radialists for elective procedures. We’ve also found the new RadBoard by Radial Assist (www.radialassist.com) an attractive platform for radial access and intervention, as it contains a plane of radiation protective material within it, outside the typical imaging zone, that may also further reduce scatter exposure to the operator. This device was developed by a cathlab tech, Gary Goff, here at St, Joe’s. Procedure times also have not been dramatically higher among dedicated radialists compared to femoralists in some published databases as well for elective PCI. The only real issue for me has been “backup” for complex PCI, and guide sizing requirments for the occassional lesion modifying devices.
We have also used standard radial access for cath and PCI as a platform for pushing forward “Same-Day Discharge PCI,” at our institution, given the absence of bleeding issues. This strategy harnesses the advantage of early ambulation with radial access, and we use the newer anti-platelet assays and agents to assure adequate anti-platelet activity for patients who leave within 4 hrs of PCI. Patients universally prefer this strategy.
We are sold on radial, and think it’s, “Right, then Left, way before considering femoral!!
Competing interests pertaining specifically to this post, comment, or both:
I’m a co-founder of Radial Assist, LLC.
I am a hard core femoral operator, I have performed over 10,000 femoral punctures, and now about 200 radial procedures, I can assure you that radial is here to stay an is not a passing fad, I have seen Cath labs in Spain where the new fellows are very unfamiliar with femoral punctures. In an ideal scenario we should be competent at both, obviously for a variety of patients from those with severe lower extremity vascular disease to old men with prostate hypertrophy who can not urinate lying down the Radial approach is preferred, and this includes rescue PCI where patients had received thrombolyitic and where a hematoma may be serious.
However having said that
however having said that, there are many ways to improve the safety of the femoral approach, ranging from using bony landamarks as a guide up to doing a routine “sheath” angiogram at the end of the procedure.
I have also used the radial approach as the default strategy for caths and PCI for over 8 years, and in several thousand procedures, including in primary PCI and find that the advantages far outweigh the disadvantages. As has already been said, the risk of access site bleeding is zero, speed is not a concern if the operator is familiar with the approach and crossover rate is less than 5%, usually due a severe loop which is apparent within a couple of minutes. Not only is the radial approach not a passing fad, I would say that it needs to adopted enthusiastically because the risks of bleeding from the femoral route are very real and serious. If an operator is comfortable doing routine cases via the radial approach, primary PCI from the radial approach is easy for the staff as well as the operator and as quick. The only exception in my practice is post-CABG patients in whom an operative note is not available and the graft status is unknown. Even in patients in shock, radial approach allows one to place an IABP via the femoral approach yet maintaining another groin available as a “backup.” Our D2B times are consistently less than 60 minutes since we started participation in the program. Radiation exposure likewise is not a concern without any elaborate equipment given that speed of the procedure is the same as femoral approach and if patient’s abdomen is covered with a lead, operator exposure for radial is same as, or lower than, femoral route.
Competing interests pertaining specifically to this post, comment, or both:
I participated in a training program organized by J & J last year as an instructor to train interventionalists in the radial approach and was compensated by J & J.
Couldn’t agree more with Van Crisco.
I switched to a 100% radial approach about two years ago (after doing nothing but femoral and the odd brachial every now and and then for 8 years) – and have never looked back.
Other than cardiogenic shcok where there’s no radial artery to feel, we do all cases radially and I agree the D2B times, radiation exposure and contrast use is no different. In fact if you use dedicated single radial catheters like the Tiger or Jackie the cath procedure time is probably lower. The arm is kept next to the right groin so it’s just like a femoral case as far as radiation. Even back-up support is darn good and can be beefed up with the Guideliner or Heartrail.
Bleeding complications are virtually none and we fail to complete the procedure radially in about 2.5% mostly due to subclavian tortuosity (I’m sure this number is lower for those doing radial procedures longer than myself). With the now available sheathless guides you can get 8F lumen transradially so even that is no longer an issue. Of course patients love it especially in the US where the radial approach is still uncommon. For graft cases I go left radial and it works fine as long as no bilateral IMA (haven’t done one of those radially yet!)
We have found that by going “radial first” our fellows are less adept at the femoral approach and actually “request” to go femoral to get the experience!
Competing interests pertaining specifically to this post, comment, or both:
None