February 7th, 2013

Arms and the Interventionalist

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According to an ESC consensus document published last week, radial artery access should be the “default” choice for PCI. CardioExchange’s John Ryan interviewed cardiologists and interventional cardiologists at different stages of their careers to find out how they view radial artery catheterization, and if the views differ among interventional fellows, faculty, and those in leadership roles.

Dr. Ryan: Do you agree with the ESC statement that radial artery access should be the first choice for PCI? Why or why not?

Megan Coylewright, MD, MPH (interventional fellow, Mayo Clinic): I do agree that radial PCI should be a part of every interventionalist’s toolkit, and I agree with the need to maintain proficiency with appropriate annual volume. I believe the statement stops short of declaring that it “should be” the first choice, but rather that it is “feasible.” This reflects the ongoing controversy surrounding the issue at many institutions, particularly as smaller sheaths and less use of GP IIb/IIIa inhibitors are becoming the norm for PCI; some feel this diminishes the difference in bleeding between the two approaches.

Michael Tempelhof, MD (interventional fellow, Northwestern University): Transradial access has been shown to be beneficial on many levels. For patients, the transradial approach is well tolerated and associated with earlier ambulation times and reduced length of hospital stay. Physicians and patients alike benefit from significant reductions in bleeding risk and cardiac death. Healthcare systems benefit from reductions in cost associated with complications and prolonged hospitalization. Finally, as recently reported in the RIFLE-STEACS trial, the patients with the highest complication rates associated with PCI have been demonstrated to derive the greatest benefit from the transradial approach.

For these reasons, I do concur with the ESC statement advocating for the transradial approach for coronary angiography and intervention. A caveat is that the transradial approach is a learned skill requiring strict adherence to a regimented, progressive training plan, as outlined in the ESC document.

Micah Eimer, MD (cardiologist, Glenview, IL): The data are pretty convincing on the lower rate of complications, and my clinicial experience confirms that. Patients who have undergone both radial and femoral approaches consistently and strongly prefer the radial approach for several reasons, including less discomfort at the site, not having to lie flat on their backs for hours, lack of bruising, and quicker recovery. As a clinician, I am happy to see fewer complications (hematomas, psuedoaneurysms, emboli) and appreciate the ability to send patients to cath without stopping warfarin.

Therefore, I do agree with the concept, but I am always cautious about substituting guidelines for clinical judgement.

L. David Hillis, MD, (Chair, Department of Internal Medicine) and Richard Lange, MD (Professor, University of Texas Southwestern Medical School): Although we think interventionalists should be proficient in both femoral and radial techniques, we’re not persuaded that “one access fits all.” Although radial access is associated with fewer vascular complications (primarily hematoma and pseudoaneurysm), its use does not convincingly reduce the occurrence of MACE. Compared with the femoral approach, the radial approach requires a higher level of training and proficiency (which may not be universally attainable). Furthermore, even in centers with extensive experience in its use, radial access is associated with a 7–10% rate of crossover to femoral access, increased operator radiation exposure, and radial artery occlusion.

Dr. Ryan: Do you feel comfortable using the radial approach?

Dr. Coylewright: Yes, we use it frequently at Mayo Clinic. Speaking with interventional fellows across the country, I anticipate that the use of the radial approach will rise steeply in the next 10 years as a result of the excellent training we are receiving from our institutions’ experienced radial operators.

Dr. Tempelhof: Proficiency in the transradial approach for PCI and catheterization of complex coronary anatomy is limited by the nascence and underutilization of the approach in the U.S. Compared with the femoral approach, there is a paucity of advanced equipment and live mentorship programs, which are required to quickly develop an interventionalist into a facile transradial operator. I am comfortable with the transradial approach for diagnostic angiography and type A PCI. However, I recognize that additional experience is required to become competent for complex PCI or cannulation of complex coronary anatomy.

Drs. Hillis and Lange: Not really. As old dogs (admittedly late in learning new tricks), we’re a part of “Gen-S” (“S” for Sones). Since we’re very comfortable with femoral and brachial approaches, using a non-femoral approach is not a problem. However, with these approaches, we don’t have to confront radial loops, spasm, and occlusion, and we are not restricted from using large guiding catheters that can be helpful in approaching complex lesions (i.e., chronic total occlusions and bifurcation or calcified lesions). In Texas, where everything is bigger and better, we don’t feel a need to abandon the femoral approach.

Dr. Ryan: What percent of your current cases are radial, and what percent do you expect to be radial in 3 years?

Dr. Coylewright: For an interventional fellow, the percent of radial cases depends a bit on the attending with whom we are working; there is a lot of variability among the staff. It is not yet a default approach in our lab. My cases are currently approximately one-third to one-half radial. My future practice will depend in part on my patient population; I see the need for complex left main PCI, rotablation for heavily calcified vessels, and CTO procedures potentially rising as our population ages. Sheath size limits the performance of these interventions via the radial artery, particularly in smaller patients.

Dr. Tempelhof: I currently complete 24% of all my coronary cases via the transradial approach. Patients’ expectations and demonstrated outcomes benefit will require that I complete 50–70% of cases via the transradial approach in 3 years.

Dr. Eimer: Our interventionalist is probably at 90% radial, and I expect that to stay the same, as its use is limited primarily by unsuitable anatomy.

Drs. Hillis and Lange: At our hospital, approximately 10–15% are performed via the radial approach. In 3 years, that will likely double.

2 Responses to “Arms and the Interventionalist”

  1. Matthew Carr, MD says:

    As I watch my colleages start doing radial cases I note that the ptca cases thay are willing to tackle and the number completed expeditiously have dropped. Having personally done over 15000 cases fomm the leg and less than 100 from the wrist (started as a Sones operator too) I am reluctant to not give my acute mi patients my very best speed and skill. Those much less experienced will probably not notice much difference between their femoral and radial cases. Talk to me again after I have done 1000 elective wrist cases and I may feel differently.

  2. I agree with Drs Hillis, Lange and Carr. Having both techniques available is important, but insisting that 80% of cases should be radial is perhaps a little “cultish”. Experienced femoral operators may have MACE rates and peripheral arterial complication rates comparable to experienced radial operators. The transition to radial will probably be smoother in training, but trainees must not be deprived of femoral experience. Perhaps another even more important issue in the future is whether or not the 75 case load number can be maintained in an era when appropriate use criteria for angiography and intervention is rigorously applied.