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Angioplasty.Org Interview Series: Transradial Approach
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Howard Cohen, MD and Kirk Garratt, MD, MSc

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
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.

    Howard Cohen, MD
Dr. Howard Cohen

Kirk Garratt, MD, MSc
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.