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Angioplasty from the Wrist: Help for Patients and Physicians

March 25, 2010 -- The transradial or wrist approach to catheter-based heart procedures, such as diagnostic catheterization, angioplasty and stent placement, has less bleeding complications, is less expensive and is much preferred by patients. Yet it is practiced in only 3-5% of cases in the United States; it is far more prevalent in Europe and around the world. But burgeoning interest in the technique from U.S. interventional cardiologists is creating a demand for more training and informational tools.

Sunil V. Rao, MD
Sunil V. Rao, MD

Sunil V. Rao, MD, FACC, FSCAI, Assistant Professor of Medicine, Duke University Medical Center, and Director, Cardiac Catheterization Laboratories, Durham VA Medical Center has been a strong proponent of the transradial approach. He states,

"There is definitely a huge demand for transradial education in the U.S., greater than we have seen in the past. There are both clinical and economic factors driving transradial interest, but the demand is outstripping the availability of educational options."

Growing Interest in Transradial
Recent evidence of this increasing demand for information was seen at the September TCT meeting in San Francisco, when a five-hour seminar on the transradial approach overflowed into the hallway and a second conference room had to be opened to accommodate the hundreds of cardiologists eager to learn about this technique from the panel of experts. An evening symposium at the same meeting was also packed, much to the delight of the event's sponsor, Terumo Interventional Systems, a company that has been actively promoting the spread of transradial access.

    Overflow crowd at the TCT

Dr. Melvin Judkins in cath lab
Dr. Melvin Judkins in cath lab

Femoral Approach is 50 Years Old
In the U.S., most catheter-based cardiac procedures are done through a small incision in the femoral or groin artery. When the femoral approach was first developed by Dr. Melvin Judkins in the 1960's, it was rapidly adopted as being much preferable to the semi-surgical brachial technique: it was easier, quicker and had less complications.

Now, almost half-a-century later, the Judkins or femoral technique has proven to be very durable: it has barely changed and is still the mainstay of interventional cardiology.

Transradial Offers Advantages
However, with the growing use of powerful anticoagulation drugs for stenting, as well as the significant increase in heavier patients (more difficult to compress the artery post-procedure and achieve hemostasis) concern over bleeding complications has become a major topic of discussion among cardiologists. Additionally, a number of recent studies have associated bleeding complications with increased mortality and morbidity.

The transradial technique lowers bleeding complications to almost 0% and allows a patient to stand up and walk almost immediately. So why isn't it used more? One reason is that most cardiologists aren't exposed to it in their training fellowships. Only a limited number of teaching institutions use the approach, so only the cardiologists who train there learn it. Once established, an interventional cardiologist must take time off from his or her practice to train and, as Dr. Rao has stated, these training opportunities are not keeping pace with the current demand.

Training Aids for Professionals
To aid in this training process, Terumo Interventional Systems yesterday announced the launch of a new web site for healthcare professionals,, which contains on-demand informational modules intended to provide physicians with an introduction to various aspects of transradial cases from arterial access through hemostasis, including tips and tricks, with contributions from leading transradialists.

In addition, Angioplasty.Org recently launched a listing of Transradial Training Courses in its Radial Access Center. Most of these courses are one or two day meetings where interventional cardiologists, nurses and technicians can get instruction, sometimes with simulators, sometimes scrubbed in on actual cases. Any hospital that is offering a transradial program can also submit the information for a free listing.

Help for Patients
Most patients are not aware that there may be a choice between two different approaches. They are given a prescription to get an angiogram and they usually are not asked a preference. But in an institution where cardiologists practice the wrist approach, they will. And they invariably choose the wrist over the femoral -- lower complications, instantly being able to walk instead of lying flat for hours and a general sense of feeling better immediately after the procedure, instead of having to be cautious about lifting things, exerting oneself, etc. Cardiologists who practice the radial approach have reported that patients seek them out. To expedite this process, Angioplasty.Org has posted a Radial Hospital Locator where patients can browse hospital centers by state in order to find one that offers radial. This listing is growing with hospitals and cardiology practices being added weekly.
    "Radial Lounge" at St. Joseph's Hospital in Atlanta
"Radial Lounge" at St. Joseph's Hospital
in Atlanta where patients go after an
angioplasty: no beds, just chairs,
wireless internet, wide screen TV and
more (photo by Chris Savas)

Growth Seen for the Future of Transradial
As more and more hospital centers begin offering the wrist approach, an increasing number of cardiologists-in-training will be exposed to it. Most interventionalists who have adopted the approach report using it in 50-90% of all cases with great success. Manufacturers of catheters and hemostasis devices specifically for the radial approach are constantly refining the equipment, making the technique easier, safer and faster. As word spreads, patients will be driving the adoption of a technique that makes their experience much better. And finally, the pressure on reigning in healthcare costs will come into play: the radial approach offers the possibility of safe and effective angioplasty on an outpatient basis. Several studies are now in process documenting these factors and measuring the cost-effectiveness of the transradial approach.

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, Sunil Rao, John Coppola, Shigeru Saito, Jennifer Tremmel 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, March 25, 2010