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Is Radial Angioplasty at a Turning Point in U.S.?
New Studies Confirm Increased Safety of Wrist Technique for Stents and Angioplasty;
Training of Cardiologists is Key Issue

September 25, 2008 (updated from September 24) -- Two recent large-scale studies confirm what a small but growing number of interventional cardiologists have seen in their own practices: for the proper patients, catheterizations and angioplasties performed from the wrist (radial) artery are safer than those performed from the groin (leg) artery, with no difference in procedural success. As previously reported by Angioplasty.Org, the M.O.R.T.A.L. Study which looked at a registry of 33,000 Canadian patients, showed 50% less blood transfusions and accompanying reductions in mortality for patient done radially. A study from Duke, published in the current journal JACC Interventions, looked at 593,094 U.S. patients and found that radial patients experienced 58% less bleeding complications.

Even an editorial in the current British Medical Journal Heart asks the questions: "Is radial approach the gold standard for PCI?"

Trends in Radial Approach for the U.S. -- 2004-2007
Percentage of cases done via the
transradial approach in U.S.

The radial technique is used far more outside of the U.S., up to 35-50% of the time in Europe, Japan, and India.

But an interesting trend seen in the Duke study was a recent and significant increase in the use of the transradial approach, which almost doubled in the first quarter of 2007, the last data used in the study.

Dr. Sunil V. Rao of Duke commented to Angioplasty.Org on this trend:

"Radial is gaining. We saw this in our paper: in the last quarter of 2007, we saw an up tick in the use of radial. And I think the timing is right. There's a lot of attention being paid to bleeding complications and their association with mortality. The focus has really been on the pharmacological therapy...but what I think a lot of people have forgotten is that the majority of bleeding complications in patients undergoing stenting is related to the access site.

"I think the radial approach has been in the background for a long time, but now we have a study showing that the radial approach is associated with reduced mortality."

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

More Comfortable for Patients
Most patients who have a cath or angioplasty must lie still on their backs for hours, to allow bleeding from the femoral artery to completely stop (hemostasis). Ironically, the chief discomfort experienced by a patient, whose coronary artery has been cleared of a major blockage without bypass surgery, is the leg pain where the catheter was inserted. And the back pain ensuing from lying still. Bleeding, vascular or nerve trauma complications occur in three to six or more patients out of a hundred: some are just minor hematomas, but some can require a transfusion.

With the radial or wrist approach, bleeding complications approach zero and nerve trauma is almost non-existent. Hemostasis can be achieved very quickly, and the patient can sit up and walk within minutes after the procedure. As Dr. Howard Cohen of Lenox Hill Hospital in New York told Angioplasty.Org, "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!' ( Dr. Cohen was profiled on yesterday's CBS Network "Early Show", discussing the "New Angioplasty" -- namely the radial approach.)

Barrier to Increased Use: Training
Since the radial technique is safer and more comfortable, then why isn't it used more? One of the biggest roadblocks to wider use is that, while all cardiologists are trained in the femoral technique, very few are exposed to the radial approach. This training is non-existent in medical school and very scattered once the physician has specialized in interventional cardiology in a Fellowship program. If the cardiology group does not practice radial, the Fellow will not learn it.

Radial training programs have been held around the world for years, in India, Japan, China, Europe -- but more are beginning to crop up in the U.S.

Terumo, a company that makes specialized catheters and related equipment for the radial approach has been sponsoring two-day hands-on seminars at Lenox Hill Hospital and St. Vincent's Hospital in New York -- and these courses have filled up weeks in advance. The Company also is sponsoring a number of activities at the upcoming TCT meeting in October.

Dr. Rao commented on the problem: "It's hard to learn new techniques once you get into practice. So I'm a firm believer that fellows need to be exposed to it during their training. And that's what we do, We insist that the fellows do at least one radial case a week at the very minimum while they're training with us, so they are comfortable with us and not have their heart rate increase when they have to do one."

    Angioplasty.Org Image
Drs. John Coppola and
Shigeru Saito during a
transradial case at a
St. Vincent's training course

When Angioplasty.Org asked Dr. Rao if groups like the American College of Cardiology (ACC) and the Society for Cardiovascular Angiography and Interventions (SCAI) ought to get involved in training cardiologists about the transradial approach, he replied:

"You're absolutely correct. The professional societies have to take a leading role in this. The data are very clear. They need to adopt this into their practice guidelines, in addition to saying, 'Here are techniques that you can use to reduce bleeding complications, dose your drugs, etc.', I think they should include a section on radial approach, talk about the advantages of it. I think the professional societies would do well to actually put on courses for practicing cardiologists on how to do the radial technique and tips and tricks and how to troubleshoot.

"What happens is the first few times that people start doing the radial approach, they say, 'This is really onerous and I'm having trouble negotiating this curve. Forget it -- I'm just going to go to the femoral approach.' And that's because they haven't gotten any formal training on how to troubleshoot -- just like you have to troubleshoot the femoral approach oftentimes, too. So you're absolutely right and that's something that no one's really mentioned before, that's the role of the professional societies in helping clinical cardiologists and practicing cardiologists adopt this technique into their practices. I think that's really important."

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 and Howard Cohen.

For patients there is also a "Hospital Locator" that lists U.S. centers practicing radial angiography.


Reported by Burt Cohen, September 24, 2008; updated September 25