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Transradial Wrist Angioplasty Saves Money and Lowers Complications Over Groin Access
Penn Medicine Analysis of 14 Studies: Lower Complication Rate with Wrist Approach Drives Cost Effectiveness; Greater Adoption of Transradial in U.S. Could Save Millions
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New Research Also Confirms Reduced Adverse Events with Wrist Access Approach
Transradial (wrist) approach to coronary angiogram and angioplasty
July 8, 2012 -- According to a new cost-benefit analysis of diagnostic angiography, angioplasty and stenting, the use of the radial artery in the wrist instead of the femoral artery in the groin for catheter access results in less vascular complications for patients and significant cost-savings for the healthcare system.

A team of researchers from the Perelman School of Medicine at the University of Pennsylvania, the University of Washington Medical Center, and the University of Pittsburgh School of Medicine, looked at 14 previously published studies that compared outcomes of the radial artery approach versus the femoral artery. They then inserted these combined statistical findings into a cost-benefit simulation model designed to estimate the average cost of care for these procedures. The results were published online first in Circulation: Cardiovascular Quality and Outcomes.

Important for Hospitals: Lower Costs for Radial
The model took into account differences between the radial and femoral approach in terms of procedure and hemostasis time, costs of repeating the catheterization at the alternate site if the first catheterization failed, and the inpatient hospital costs associated with complications from the procedure. The researchers found the radial approach cost hospitals $275 less per patient than the femoral approach.

Although common perception of the radial technique is that it takes longer to perform, the researchers calculated the difference at only 1 minute 23 seconds. There was a small increase in fluorscopy time noted, but it was less than a minute. Interestingly, the researchers extrapolated that in order to bring the femoral approach equal in costs to the radial, the radial approach would need to average 20 minutes longer. They concluded that:

"...none of the changes to cost variables brought the net cost savings to a point that would favor femoral catheterization. Widespread adoption of radial catheterization could result in substantial savings for the US healthcare system given that over one million coronary catheterizations are performed in the United States annually."

Important for Patients: Less Complications
Of significance for patients was the finding that the radial approach results in far less vascular complications: access site bleeding, hematoma, and more. Complications in the femoral approach were more than three-fold: 3.3% for femoral, compared to 1% for radial. In fact, it was the expense incurred in dealing with complications that was the major driver in the lower costs of radial.

But the costs of complications for patients are not measurable merely in dollars. The pages of Angioplasty.Org's Patient Forum are filled with hundreds of patient stories, describing complications from femoral procedures, some minor, quite a few major, involving nerve damage, pain and suffering. Again, the complication rate is low for both approaches, but if two out of three complications can be eliminated, that constitutes a significant gain for patients.

A Call for Increased Adoption of Radial in the U.S.
Although in Europe and other countries, the wrist approach has been used extensively for both diagnostic and interventional coronary procedures since it was first performed by Dr. Ferdinand Kiemeniej twenty years ago, the United States has been far behind: less than 10% of diagnostic procedures and even less PCIs are done via the wrist.

As Matthew D. Mitchell, PhD, senior research analyst in the Center for Evidence-based Practice at Penn Medicine and lead author of the study, stated in a press release:

"Radial artery access is the primary mode of access for catheterization procedures in Europe, Canada, and Japan, but has not gained widespread acceptance in the United States, possibly stemming from concerns about increases in procedure time, radiation exposure, and access failure in patients. This study suggests that the adoption of radial catheterization could be a more viable option for many hospitals and health systems in the U.S., lowering costs and reducing complications for patients."

One of the barriers to increased use of the radial technique in the U.S. is the lack of training -- most interventional cardiologists have not been exposed to the radial approach in their fellowships. But this is beginning to change, as the Society for Cardiac Angiography and Interventions (SCAI) and other professional organizations and hospital centers begin to offer more training programs. A complete list of such training opportunities can be found in Angioplasty.Org's Transradial Training Courses page.

Is Radial "Better" Than Femoral?
While there is a sense of professional competition between the "radialists" and the "femoralists", most interventional cardiologists agree that it is helpful to have both approaches available and to choose which one is best for each individual patient. Some patients are not ideal for the wrist approach; some, especially those with extensive peripheral disease or obese patients, are not ideal for the femoral approach. And complication rates vary. As co-author of the study, Dr. Craig A. Umscheid, stated, "The savings from radial catheterization may not be as significant in sites with very low femoral access complications or excessively long radial catheterization times. But overall, our study demonstrated that the savings from reduced vascular complications outweighed the increased costs of longer procedure times and access failure associated with radial artery access by a large margin."

What About Femoral Closure Devices?
The use of vascular closure devices (VCD) for the femoral approach (e.g. Angio-Seal, Mynx, StarClose) can certainly reduce the compression time needed before the patient can be ambulatory. But there is an additional expense for these devices which are used far more in the U.S. than in other countries. While some data points to possible lower complications when VCDs are used, there is also a subset of complications specific to their use (migration of hemostatic material, etc.). In the Penn Medicine cost-benefit analysis, vascular closure devices were not factored in because, as Dr. Mitchell told Angioplasty.Org:

"The cost of a closure device would drive up the cost of the femoral procedure even more, though it would presumably be offset in part by a savings in hemostasis time costs. We talked about that in the discussion section of the paper, and the cost difference was why we did not assume use of a closure device in the cost-benefit analysis. Excess complications would have to be virtually eliminated to realize any net savings compared to radial catheterization."

The study was funded under National Institutes of Health/National Center for Research Resources grant (RR025015) and the National Institute of General Medical Sciences Models of Infectious Disease Agent Study (MIDAS) grant (1U54GM088491-0109).
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About Penn's Center for Evidence-based Practice (CEP)
Penn Medicine's Center for Evidence-based Practice (CEP) is one of the only comparative effectiveness centers in the U.S. based in an academic health system instead of in a commercial or government insurer. This feature allows CEP to focus on topics that other centers might overlook, especially topics relating to clinical practice and the quality and safety of care. In its six year history, the center has completed nearly 200 evidence reviews, serving hospital administrators, physicians, and nurses working to improve the quality, safety and value of care across Penn Medicine.

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 created the "Radial Access Center for Transradial Approach" in 2007, 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, Mauricio Cohen, John Coppola, Shigeru Saito and Jennifer Tremmel. The section also maintains a listing of upcoming training courses in the transradial approach.

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!'

The "Radial Access Center for Transradial Approach" is supported by an unrestricted educational grant from Medtronic Cardiovascular.

Reported by Burt Cohen, July 8, 2012