Getting to the Heart of the Matter on Orlando Medical News

Getting to the Heart of the Matter

By: MARTIN SCHILDHOUSE

For Diagnostic and Interventional Coronary Procedures, the Wrist Offers an Alternative Access Strategy with Potential Clinical and Patient Satisfaction Benefits

Did You Know?

There is more than one way for an interventional cardiologist to gain arterial access to the heart when performing diagnostic or interventional procedures (angioplasty).
There is less risk of bleeding complications at the puncture site using transradial access (wrist) than the more commonly used femoral access (groin).
Women are more likely than men to suffer bleeding complications during diagnostic and interventional procedures (PCI) procedures and therefore may have an added safety benefit when these procedures are performed via transradial access.
Patients are able to sit-up and move around sooner post-procedure when transradial access is used than when femoral access is used.
Patients familiar with transradial and femoral access options, as well as their associated benefits and issues, heavily favor transradial access.

Evolution or Revolution?

For more than 30 years, interventional physicians have been treating cardiovascular disease with a minimally invasive approach, using catheter-based therapy to access the body's circulatory system. Gaining access to the vasculature can be approached in several ways, through the femoral artery (groin), the brachial artery (elbow) and the radial artery (wrist). The most prevalent method in the United States is through the femoral artery (Judkins technique; developed in the 1960s by Dr. Melvin Judkins). This is due in part to the size of the femoral artery, as well as it offers a fairly direct shot to the heart. While this is the most common approach in the United States (97 percent of cases), it is not without complications and risks, the most common being access site bleeding. With the introduction of drug-eluting stents, we have seen an increased use and duration for anti-platelet drug therapy in an effort to reduce the potential for early and late occurring thrombus formation in the treated artery. As these drugs are administered prior to a procedure, they also appear to have added to the risk of bleeding complications during and post-procedure. The complication rate is generally quoted as occurring in approximately three percent of cases.

In the late 1980s, a French-Canadian physician, Dr. Lucien Campeau, began using the right radial artery as an entry point for diagnostic procedures. This artery, while slightly smaller than the femoral artery, is large enough to allow most catheters to enter and reach the coronary anatomy.

By 1992, a research team in Amsterdam, headed by Dr. Ferdinand Kiemeneij, began using the transradial technique for interventional procedures. And, while initial procedures were somewhat limited by a lack of suitable equipment, this is not the case today. Physicians now have access to an assortment of specialized transradial technology that offers lower profile catheters, atraumatic sheaths, and stents for treating many types of conditions. Transradial access outside the United States ranges from 25 – 90 percent of cases in some countries, including China, France and Japan.

Over the past several years, more and more U.S. interventional cardiologists are being trained in transradial access, expanding treatment opportunities and challenging the status quo.

As previously indicated, the femoral access approach does have limitations, which includes a predictable rate of bleeding complications (5-15 percent); procedural challenges with gaining access and successfully providing post-procedure groin compression in morbidly obese patients; patient reports of discomfort and incremental staff time required to monitor patients post procedure.

Benefits of Transradial Access

Most of the disadvantages of the femoral technique are nonexistent in the transradial approach. In fact, the following benefits of transradial access are generally commonly recognized worldwide:

Decreased incidence of major entry site complications, especially bleeding; even more pronounced for women
Significantly minimized risk of nerve damage, which is more common with the femoral approach due to proximity of the femoral artery to the femoral nerve
Easier vascular access and hemostasis for obese patients as the radial artery rests close to the skin surface, allowing for a simple and straight-forward needle puncture
Decreased time to patient ambulation and discharge
- No need for the patient to lie flat for 4-6 hours, as required with the femoral approach
- Shorter hospital stays, resulting in lower cost burden to healthcare system
- Greater potential for outpatient procedure
Decreased post-procedural cost resulting from complications and follow up visits
Improved patient ambulation, comfort and overall satisfaction
More efficient procedure that significantly reduces cath lab staff time in administering post-procedure access site compression and patient monitoring

"We are a tertiary care center and treat many high-risk PCI patients and STEMIs," said Zaheed Tai, D.O. "Today, we treat approximately 75 percent of our patients using transradial access. With transradial access, we virtually eliminate the risk for post-recovery access site complications, such as bleeding. In addition to the clinical benefits transradial access provides, we find that patients truly appreciate this approach as it creates less discomfort for them and it significantly reduces their time to ambulation as compared to patients treated via femoral access."

Which approach is best for the patient, transradial or femoral? It is a question that patients facing a diagnostic or interventional procedure may want to explore with their interventional cardiologist or other treating physician prior to a coronary diagnostic or interventional procedure.

For more information, visit www.Angioplasty.org ("Radial Approach") or www.terumois.com.

Martin Schildhouse is a senior communications consultant with Storch-Murphy Group, Ltd., specializing in the medical device market.