Angioplasty from the Radial Artery in the Wrist is Safer, Says Study of 600,000 Patients

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Overview of
Radial Access

Wrist Angioplasty Associated with 50% Less Blood Transfusions and Lower Mortality
(Mar 19 '08)

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Trends in the Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention: A Report From the National Cardiovascular Data Registry
-- JACC Cardiovascular Interventions

September 16, 2008 -- A study, published in the current issue of the Journal of the American College of Cardiology: Cardiac Interventions, looked at 593,094 angioplasty and stent patients and found that those patients who had procedures done from the radial or wrist artery experienced 58% less bleeding complications than those who had their procedures done from the femoral artery in the groin -- yet the radial approach is used less than 2% of the time in the U.S.

Recent findings, for example, the M.O.R.T.A.L. Study, have shown that patients undergoing angioplasty or stenting (called Percutaneous Coronary Intervention or PCI) who experience bleeding complications and transfusions have a significantly increased risk of death -- and that the transradial approach can greatly reduce that mortality risk.

The association of bleeding and death has become even more important as more complex cases are being done, cases which require increased use of antithrombotic and anticoagulant drugs, all of which increase the risk of bleeding. Much time and money has been spent in developing new drugs, such as bivalirudin (Angiomax®), which reduce bleeding. But, as Dr. Sunil Rao, lead author of the study told Angioplasty.Org:

Sunil V. Rao, MD, FACC
Duke Univ. Medical Center

"There's a lot of attention being paid to bleeding complications and their association with mortality, and the focus has really been on the pharmacological therapy, how you can make different pharmacological choices or dose your drugs appropriately.

"What a lot of people have forgotten is that the majority of bleeding complications in patients undergoing stenting is related to the access site. The radial approach has sort of been in the background for a long time, but I think radial is gaining. We saw this in our paper: in the last quarter of 2007 we saw an uptick in the use of radial."

Dr. Rao's study analyzed outcomes from the American College of Cardiology's National Cardiovascular Data Registry for more than a half-million procedures performed during 2004-2007 and found that overall only 1.32% of the procedures were done from the wrist. Despite the published findings of increased safety, cardiologists in the United States use the radial approach rarely, although it is used far more frequenty in Europe, India and Asia -- upwards of 50% in some countries. Dr. Rao continued:

"The value of our study is that, despite all that evidence out there, radial is just being used in a very very small minority of patients, and in particular, it's being used less often in patients who are at high risk for those types of bleeding complications, like females and the elderly and so forth."

While the overall reduction in bleeding was 58%, Rao's study outcomes actually showed greater gains for the highest risk patients: women had 62% less bleeding; patients with Acute Coronary Syndrome (ACS) had 61% less; while patients under 75 years of age had 69% less bleeding, those 75 and older still had 29% less bleeding complications than the equivalent cohort of elderly femoral patients.

Dr. Rao cited several reasons for the low frequency use of the radial technique in the U.S.:

"Number one, there is this perception that it's a niche procedure and that it takes a long time to learn it. There's no question there is a learning curve to it. But, you know, all of us have learned to do angioplasty, so I don't see any reason why we can't relearn any technique.

"The second reason is that I think there is a fair amount of learning inertia on the part of practicing cardiologists: they are very comfortable doing things a certain way and they are loathe to change that.

"The final thing is that, at least in this country, there hasn't been a concerted effort on the part of the device industry to push the radial approach. The companies that make specific radial catheters have a dominant presence in Southeast Asia, for example, where the radial approach is very common. Whereas in this country I think they are just starting that marketing push. And my sense is that we're probably going to see a continued increase in the adoption of radial as these papers come out, and as the device industry starts paying attention to that."

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About The Radial Access Center on Angioplasty.Org
To assist in educating the professional and patient population in the U.S. about the this technique, Angioplasty.Org has created the "Radial Access Center for Transradial Approach", a special section devoted to information and news about the transradial technique, for both patients and physicians. The Radial Center features interviews with leading practitioners of the radial technique, such as Drs. Jeffrey Popma, R. Lee Jobe, John Coppola, Shigeru Saito, Kirk Garratt, Tak Kwan and Howard Cohen.

For patients there is also a "Hospital Locator" that lists U.S. centers practicing radial angiography. As Dr. Howard Cohen of Lenox Hill Hospital in New York says of the wrist technique, "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!'

Reported by Burt Cohen, September 16, 2008