Wrist Angioplasty Associated with 50% Less Blood Transfusions and Lower Mortality

Wrist Angioplasty Associated with 50% Less Blood Transfusions and Lower Mortality
Canadian Registry of 32,822 Patients Compares Percutaneous Coronary Interventions (PCI) from the Trans-Radial Approach (Wrist) and Femoral Approach (Leg)

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Angioplasty from the Wrist: Transradial Approach Offers Benefits to Patients and Physicians

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The Association Of Arterial Access Site At Angioplasty With Transfusion And Mortality The M.O.R.T.A.L Study: (Mortality benefit of Reduced Transfusion After PCI via
the Arm or Leg)
-- Heart (BMJ)

March 19, 2008 -- A study of over 30,000 patients that examined every angioplasty done in British Columbia from 1999-2005 was just published online (before print) in the British journal Heart and the conclusion carries an important message for the interventional cardiology community:

"...trans-radial access was associated with a halving of transfusion rate and a reduction in 30 day and 1 year mortality. Although retrospective and non-randomized these data generate the hypothesis that radial access may be associated with improved outcome after PCI, likely through a reduction in bleeding and transfusion."
-- The M.O.R.T.A.L Study (Mortality benefit of Reduced Transfusion After PCI via
the Arm or Leg)

These conclusions may give more incentive for expanded use of the radial approach and credence to its advantages, something that interventional cardiologists who practice both femoral and radial approaches have been discussing for years.

These advantages include: patient safety, with less bleeding complications, hematomas and possible nerve trauma, as well as patient comfort, allowing patients to sit up, stand and walk immediately after the procedure. The femoral approach requires patients to lie still on their backs for hours to achieve hemostasis.

Many of these observations can be read in interviews posted in Angioplasty.Org's Radial Access Center, the most extensive collection of information about the transradial approach on the internet for both patients and professionals.

John T. Coppola, MD
St. Vincent's Hospital, Manhattan

In one recent interview, Dr. John T. Coppola told Angioplasty.Org why he decided to learn the radial technique and begin doing procedures from the wrist -- his experience underscores the conclusion of the Canadian report:

"As director of the cath lab at St. Vincent's Hospital, I had to review all of the complications, and through my 13 years doing this, I realized there were patients who were dying from complications from the femoral approach. They would have bleeding complications that would lead to renal failure, sepsis, and those things would snowball.

And after having a successful angioplasty, these patients would die of a complication directly attributable to bleeding from the femoral site."

Although excessive bleeding and blood transfusions after angioplasty have been associated with increased mortality in a number of studies, this Canadian registry analysis, due to its extensive breadth in numbers of patients, is among the first to observe a difference in mortality when comparing the femoral and radial approaches. As the authors state:

"We now present the first data to support the hypothesis that radial access, with a proven lower incidence of access site related bleeding and transfusion, may be associated with a reduction in mortality, independent of other major outcome predictors.

"The principal findings of this study are a reduction in 30 day and 1 year mortality associated with a halving of transfusion rate using trans-radial access instead of femoral in all-comers to PCI. We confirm transfusion-status as an important independent predictor of 1 year mortality and support the suggestion that safety and bleeding concerns should move to the forefront of the PCI agenda."

The results of this study may have significant implications, especially in the United States. Although the trans-radial approach is used in up to 40% of all procedures done in Europe and Japan, usage in the U.S. is in the low single digits, partly because the radial approach can be more difficult to learn and is not routinely taught in most cardiology fellowships. Other issues, including reimbursement and administrative issues, have hampered the spread of the radial technique in the States.

Radial access for angioplasty was developed in the early 1990's, in Canada and The Netherlands, as an alternative "on-ramp" to the body's arterial highway, and it allowed cardiologists to thread catheters, balloons and stents to the heart via the radial artery in the wrist instead of the femoral artery in the leg/groin area.

Increasingly, cardiologists are discovering the advantages of the wrist approach, especially in certain patients, such as obese individuals (where femoral access can be complicated) and those who require substantial use of anticoagulation or antithrombotic therapy (IIb/IIIa inhibitors, clopidogrel, and other pharmacologic agents) which are used to prevent thrombus and blood-clotting during and after stenting procedures.

Heart centers in the U.S., where the trans-radial technique is utilized extensively, have begun more and more to offer training courses for physicians and cath lab personnel. A recent symposium with hands-on lab experience was held at the Lenox Hill Heart and Vascular Institute of New York where Dr. Howard Cohen uses radial in over 90% of his cases. On April 2, 2008, Dr. Coppola will be offering a free one-day course on the radial technique at St. Vincent's, also in New York.

For more information about the transradial approach, visit Angioplasty.Org's Radial Access Center.

(Reported on March 19, 2008 by Burt Cohen, Angioplasty.Org)