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Angioplasty from the
Wrist: Transradial Approach Offers Benefits to Patients and
Physicians
Transradial Access
Gaining with U.S. Cardiologists Because of Lower
Bleeding Complications and Increased Patient Comfort
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February 17, 2008 -- New York --
Last week two catheterization suites at Lenox Hill Hospital in
New York City were taken over by cardiologists Dr. Howard Cohen
and
Dr. Kirk Garratt in order to teach visiting cardiologists
how to perform angioplasty in a different way --
from the
wrist.
The technique is called transradial
angioplasty because cardiologists use the radial artery near
the wrist as the
entry point,
snaking
their thin
catheters
and wires through the body's circulatory "highway" to the heart,
where they are able to expand a balloon, place a stent and open
a blocked artery without surgery.
Transradial
angioplasty, first performed 15 years ago, is used
almost 40% of the time for cardiac
catheterizations
and angioplasties
done in
Europe,
Japan
and
India. But in the U.S., the percentage has remained in the low
single digits, despite the fact that the radial approach offers
a number
of benefits,
such as significantly lower bleeding complications and higher patient
comfort.
Most percutaneous interventional (PCI)
procedures in the U.S. are done via the femoral artery, located
in the leg/groin area.
Kirk Garratt,
MD, MSc. |
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But , according
to Dr.Kirk Garratt, Director of Clinical Research at Lenox
Hill Heart
and
Vascular Institute of New York, that may be changing due in
part to courses such as theirs:
"Despite the
benefits of transradial access, most fellowship training programs
continue
to train clinical and interventional cardiologists using a
transfemoral technique. That perpetuates the practice. "Here
at Lenox Hill,
we make special efforts to train our fellows in competency
with the radial approach. Half of the fellows we graduate end
up using
radial access as their preferred access route, if for no other
reason than to capture that differentiator in a competitive marketplace." |
Patient Preference
Patients who have had
an angiogram or angioplasty from the femoral approach are familiar
with the
need to lie flat on their back for many hours to allow
the femoral artery to stop bleeding. But patients whose cardiologists
use the radial approach have a very different experience.
Dr. Howard Cohen, Director, Division of Cardiac
Intervention at Lenox Hill, explains why he uses radial access
in over 90% of his cases:
"All the
studies that have ever been done show that patients would
much prefer transradial access to transfemoral access --
it's just much more comfortable for the patient. The patient
can get up and walk immediately. We can have patients walking
back to the room following the procedure, if they haven't
been heavily sedated -- it's perfectly safe to do that.
"And
patients who have problems with their back, they don't
have to stay in bed for a long period of time because of
bleeding
problems.
"Patients really prefer it. 95% of people who've had it
both ways would say 'I'm coming back to you, Dr. Cohen
because I like this transradial a lot better than the other
way!'"
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Howard
Cohen, MD |
Patient Safety
Although patient comfort is
important, there are significant medical benefits to the transradial
approach
as
well, such as significantly lower bleeding complications. The type
of problems seen most often in the femoral/groin
approach are various bleeding
complications
at
the
catheter access
site, especially in heavier patients. Sometimes these complications
can be serious. Called retroperitoneal bleeds, they occurs backwards
into
the body,
and
are not visible immediately.
A patient can be discharged only to return within a short period
in pain or in need of a transfusion due to blood
loss. In fact, research has shown that "One of the
most important
risks
associated
with PCI is the risk of bleeding after the procedure." ¹ This
has become
increasingly
critical as powerful anticoagulant
and antiplatelet medications are used more and more during PCI
procedures to avoid blood clots.
But these types of bleeding
complications are greatly reduced using the transradial approach.
As Dr. Cohen describes:
"When you're finished with a case,
you just pull the sheath and you put on a pressure bandage, a radial
band
that
takes
fifteen
seconds
to terminate the case. There's no closure device. It's relatively
inexpensive, and complications are very low -- they approach
nil as a matter of fact."
Both Drs. Cohen and Garratt stress that no medical
procedure is without complications, and not all patients are candidates
for the
transradial approach -- for example, an individual must have normal
dual circulation of their radial and ulnar arteries. But for many,
the
wrist approach
may provide a better and safer experience.
While more cardiologists are learning the technique,
due to courses like the one at Lenox Hill and the upcoming annual
seminar at St. Vincent's Hospital in New York, it may be a challenge
for some patients to find a hospital where the transradial approach
is used.
Dr. Garratt advises:
"A patient who has heard about transradial
access certainly should ask their doctors about its use for
their procedure. Now
not
all doctors will be anxious to comply -- but, as with everything
in medicine,
ultimately the patient is the consumer and should have the
final say in what happens to their bodies."
More information about the transradial technique
can be found at Angioplasty.Org's "Transradial
Access Center", including training
courses for physicians, and for patients, a listing of hospitals
that offer the transradial technique.
¹ O'Neill, William W., "Risk
of Bleeding after Elective Percutaneous Coronary Intervention",
N Engl J Med 2006 355: 1058-1060
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