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Angioplasty from the Wrist: Interest Growing But Lack of Training Limits Spread in U.S.
Practitioners of the Transradial Approach Agree that More Exposure to the Technique is Needed at National Cardiology Meetings

April 17, 2009 -- The transradial approach to catheter-based procedures, where the radial artery in the wrist is used for angioplasty and stents, is in its infancy in the United States, even though it is widely utilized in the rest of the world.

In the past two years a number of large studies have been published showing a significant reduction in bleeding complications and mortality with the wrist approach, as compared to the standard access site used in the U.S. -- the femoral (or groin) artery. Moreover, patients are able to sit up and walk almost immediately after the wrist procedure, increasing not only their comfort and recovery time, but the cost-effectiveness of the procedure, a major issue in today's healthcare environment.

The question raised by this information is why the use of radial access in the United States is in the low single digits, when it is the default access site for many cardiologists in other countries?

Just one example of this disparity could be seen in an important study at last month's ACC.09 meeting. Dr Giles Montalescot of Paris presented results from the ABOARD study of 352 non-ST-elevation ACS (NSTE-ACS) patients -- speed of treatment was being studied, but an interesting side-fact was that the transradial approach was used in 84% of this very high risk population. Dr. Montalescot told Angioplasty.Org that the radial approach is his default access and that he is able to use it in virtually all of his cases.

A sea of poster presentations at a national cardiology meeting
A sea of poster presentations
at a national cardiology meeting

U.S. cardiologists who practice the radial approach have identified lack of training opportunities as a major roadblock to its proliferation. Catheter basics are normally taught during an interventional cardiology fellowship and, if the hospital center doesn't use the radial approach, it isn't taught. Once in practice, it becomes more difficult for physicians to find the time to learn a new technique.

Yet at this year's ACC.09, one of the largest cardiology conferences in the U.S., exposure to studies involving the transradial approach was limited to six poster presentations and one 15-minute oral presentation, although supplementary literature and simulation displays were provided by the manufacturers of transradial catheters, wires and sheaths.

When Angioplasty.Org asked Dr. Sunil Rao, a noted researcher on the topic of bleeding complications, whether groups like the American College of Cardiology (ACC) and the Society for Cardiovascular Angiography and Interventions (SCAI) ought to get involved in training cardiologists regarding 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 societies would do well to actually put on courses for practicing cardiologists: how to do the radial technique, tips and tricks, and how to troubleshoot.

"So you're absolutely right. That's something no one's really mentioned before -- 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."

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

Jennifer Tremmel, MD
Jennifer Tremmel, MD,
Director of Transradial Interventions at Stanford

Dr. Jennifer Tremmel, Director of Transradial Interventions at Stanford in California and Clinical Director of Women's Heart Health at Stanford Clinic, stressed to Angioplasty.Org her concern that visibility for new techniques, such as transradial, is important at the national meetings:

"People walk away from these meetings with the sense that 'This must be important because it came up a lot and it got a lot of press' -- so they're thinking, 'I'd better learn about this.'" That's why we all go to these meetings.

"But I think it's interesting, for example, that at this ACC, [radial] was not talked about very much -- if we don't say anything, people will walk away thinking that this isn't important."

Interest in radial angioplasty is there. Recent polls on major cardiology web sites have shown more than 50% of cardiologists feel the radial artery should be either the default access site, or utilized in at least 50% of their cases.

Those physicians who use the radial approach in the cath labs of the United States feel that the time has come for more extensive training in transradial access techniques at these national meetings. Given the increasing number of studies affirming its advantages, it is probably only a matter of time until this happens.

For a brief description of the presentations from the recent American College of Cardiology 58th annual scientific session that involved the radial approach in one way or another, see the accompanying article: Transradial at ACC.09.

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 and interventions.


Reported by Burt Cohen, April 17, 2009