As part of
its interview series with cardiologists who practice
the transradial approach from the wrist for diagnostic and
PCI procedures, Angioplasty.Org
recently talked with two
members
of the interventional
team at the Lenox
Hill Heart and Vascular Institute in New
York City: Dr. Howard Cohen and Dr. Kirk Garratt. |
Lenox Hill Hospital |
|
Dr.
Cohen is director of the Division of Cardiac Intervention at
Lenox Hill. He came to NY from the University of Pittsburgh
Medical Center, where he headed one of the leading cardiology
programs in the country.
Dr. Cohen is nationally and internationally
known for his pioneering work with the TandemHeart®, a percutaneous
left ventricular assist device. He has been
perennially mentioned as Best Doctor in New York and was recently
featured in New
York Magazine (PDF link) performing a "high risk" coronary
intervention on a renowned musician and conductor who has since
been able to resume his performances at age 91.
|
|
Dr. Howard
Cohen |
Dr.
Kirk Garratt |
|
Initially a doctoral candidate in molecular
biology and biochemistry at the University of California, Irvine,
Kirk Garratt subsequently moved into the study of medicine at
that institution. After training in interventional cardiology
at the Mayo Clinic, and
then joining
the faculty there, he helped develop key devices including coronary
stents, lasers, and atherectomy catheters.
During this period
he also oversaw a pioneering telemedicine system for the
delivery of angioplasty services to rural hospitals with cath
labs but
no cardiac surgery. It was at Mayo that he learned the transradial
technique which he brought along with him when he joined
Lenox Hill in 2005.
|
For more about the transradial approach, visit our Radial
Access Center.
Q: What percentage of your cases do you do using
the transradial wrist approach?
Dr. Cohen: I would say mine is probably in excess of 90%.
Diagnostic, intervention, I try to do every coronary and diagnostic
case transradial.
Dr. Garratt: Currently, I do about 2/3 of
my cases transradial -- it's my routine first access of choice,
and my standard practice. Dr. Cohen has a slightly higher threshold
for moving away from the
radial artery than I do. I like the radial artery for all the usual
reasons, but at the same time I have respect for the fact that radial
access can be problematic for some people. Small people, particularly
smaller women, tend to have smaller radial arteries. Although it's
possible to get access through them, the vessel will always spasm
to some degree, even with the use of vasodilator agents. So for thin,
smaller people, particularly women,
my sense is that the femoral access is a bit more comfortable, and
if they're not obese, the risk profile is still adequate, favorable
enough, to use the femoral approach.
Q: What do you mean by the risk profile?
Dr. Garratt: The risk of bleeding. When patients are very heavy,
it gets harder to put the femoral sheath in just the right spot.
Landmarks are displaced, and it's just a harder task to hit the
femoral artery in the sweet spot. We know very clearly now that
getting the femoral access right is essential to having a low bleeding
complication rate. So for the heavy patients, it makes a lot of
sense to try to use the radial access whenever you can.
Q: One question we ask everyone in
this series is what do you see as the main advantages to the
radial approach?
Dr. Garratt: The two major advantages to radial access are
(1) that there are fewer bleeding complications associated with it,
and
(2) that you can sit the patient up right away afterwards. That translates
into a safer procedure, and a more comfortable procedure. So the
ideal patient for transradial access is someone who has either a
problem or an issue that might make them at risk for bleeding, or
the patient for whom comfort measures are primary. We try to make
all patients comfortable, of course, but for the fellow with chronic
back problems, or for perhaps an agitated or anxious patient who
has difficulty lying still, or for a patient who has an orthopedic
problem that might make holding themselves in one position for a
long period of time hard, those are the sorts of the patients that
I think get the most mileage out of the transradial approach.
Dr. Cohen: I think it's the safest way to
do it, for several reasons. One is that atherosclerosis is not a
disease that's localized
in a single area. Often, the abdominal aorta, in particular, is a
minefield of atherosclerosis; the aortic arch also has a lot of atherosclerosis.
And for patients who've got abdominal aortic disease, we don't have
to deal with that; we don't have to cross the aortic arch, which
can be a problem.
Second and the most important reason is that
it avoids all the complications associated with access. In this
day and age, a high percentage of
the complications associated with percutaneous intervention are those
associated with access, either because the patient's body is either
too thin or too heavy. Elderly patients we've known for a long time
have a high complication rate associated with access. And these are
all magnified by anticoagulation that is required for intervention,
if you use IIb/IIIa receptor antagonists, or a patient who's had
thrombolytic therapy. So I use it whenever I can, particularly in
patients with acute MI. I don't worry about “is it safe to
give IIb/IIIa or not because of access site problems” -- it's
never a problem. And frequently the patient you really want to continue
the IIb/IIIa receptor antagonist on, because they have a heavy thrombus
burden and acute MI, you have to stop it because they have access
site bleeding problems. And you just don't have that with the radial
approach.
The other thing -- all the studies show that
patients would much prefer transradial access to transfemoral access.
It's just much
more comfortable for the patient. The patient can get up immediately.
We have patients walking back to the room following the procedure,
if they haven't been heavily sedated. It's perfectly safe to do that.
It's very unusual for a patient who's had both transfemoral and transradial
access, to say that they prefer transfemoral access. 95% of people
who've had it both ways would say “I'm coming back to you,
Dr. Cohen; I like this transradial a lot better than the other way!”
Q: Regarding femoral access site complications, don't femoral closure
devices help reduce that?
Dr. Cohen: A lot of studies have hoped to show that with femoral
arterial closure devices complications can be avoided compared to
manual hold, especially in patients who are heavily anticoagulated
and have antiplatelet therapy. But particularly the early studies
showed that there was no advantage, in fact there was a disadvantage
with femoral closure devices. The femoral closure devices have improved
recently, and they are somewhat better, but if you really want to
have your complications approach zero, best do it by transradial
access.
Q: What about advantages for hospital administrators in terms of
cost-control?
Dr. Garratt: We know that the use of the radial artery is associated
with fewer bleeding complications, and bleeding complications greatly
increase hospital stay, resource consumption, and have a direct impact
on overall mortality. So the physician and the hospital both benefit
from use of the radial approach by minimizing those negative aspects
at the practice.
Dr. Cohen: Studies have shown that transradial is cost-saving
for the hospital. Unfortunately now, most intervention in this country
is done as an overnight stay, and that's not necessary; we could
do same day intervention in a high percentage of patients. But it's
for billing issues: it makes more money if you keep the patient overnight
than if they go home the same day.
Dr. Garratt: There currently aren't good reimbursement pathways
for out-patient angioplasties in any part of the country. Outside
the U.S. that's taken hold, and short stay, out-patient facilities
have been quite successful. So hopefully as we move towards that
kind of practice in the U.S. that would model an out-patient surgical
approach, we would hope to see some recognition of the value added
with use of the transradial access, and perhaps compensation would
reflect that.
Q: There's been an evolution in the
last decade in terms of catheters and equipment -- has this made
the radial technique more do-able
than it used to be?
Dr. Cohen: I think so. I can do pretty much anything from
the transradial approach that people who are committed to the transfemoral
approach can. We can use the Rotablator, other devices, we can use
crush technique, we can do all these things. Ordinarily I use the
6F guide, or the 5F guide in some patients -- I would say 99% of
the time we use a 6F guide. But I've used a 7F guide; I've even used
an 8F guide in the radial artery, in a big patient.
Q: What about training? You've started
running courses, but how does a cardiologist who does only femoral
learn this new technique?
Dr. Garratt: Well, a terrific way to learn is to come to our
training course at Lenox Hill Hospital. Certainly working with someone
to give you insight into the fundamentals of the approach, someone
who can teach you techniques which have proven successful, and someone
who can serve as a resource to help you with questions or
problems as you start the practice, is going to let a new practitioner
develop the skill quickly and effectively. Once you've had an opportunity
to understand the anatomy, the approach, the technical issues, and
you've had enough opportunity to see a few cases being performed,
most interventionalists will be able to go right back into their
practice and start. Attending a course where you have a couple of
days of intense exposure to how it's done, and given an opportunity
to ask questions of people who do this a lot, will make the launch
of that practice a lot easier.
Dr. Cohen: I think the learning curve in the absence of a
course is fairly steep. To feel comfortable, you probably have to
do about a hundred cases, and to feel totally comfortable, about
two hundred. I think a course can flatten the learning curve considerably,
because there are a lot of tips and tricks. The access is a little
bit more difficult. The manipulation of the catheters is a little
bit more difficult. But once you learn these little things, it's
not hard, and any experienced and technically adept interventional
cardiologist can learn this technique and be good at it.
But you have to be committed to it, you can't
say “Well, I
can do it” and do it every once in a while. To really be good
at it, you've got to do it all the time, use it as your preferred
technique, and then you can really become good at it.
Q: In the U.S. radial access is in the low single digits. Why is
that and do you see it changing?
Dr. Garratt: I think it'll be a slow process. Despite the
benefits of transradial access, the fact of the matter is that most
fellowship
training programs continue to train clinical and interventional cardiologists
using a transfemoral technique. So each year we graduate a new group
of young practitioners who are oriented to the transfemoral approach.
That perpetuates the practice.
Here at Lenox Hill, we make special
efforts to train our fellows in competency with the radial approach.
I would say about half of the fellows we graduate leave and end
up using radial access as their preferred access route, if for no
other
reason than to capture the differentiator that it provides for
them as they go to work as a new physician in a competitive marketplace.
Q: Speaking of that differentiator,
what's the patient's role
in finding someone who performs radial access?
Dr. Garratt: A patient who has heard about transradial access
certainly should ask their doctors about its use for their procedure.
Now not all doctors will be anxious to comply, but as with everything
in medicine ultimately the patient is the consumer and should have
the final say in what happens to their bodies.
Patients looking for hospitals where the transradial
approach is used can use Angioplasty.Org's Radial
Hospital Locator.
Interventionalists looking for training opportunities
can find them in our Radial
Access Center.
This interview was conducted
in January 2008 by Burt Cohen of Angioplasty.Org.
|
