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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

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
Kirk Garratt, MD, MSc.

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!'"

    Howard Cohen, MD
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