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Angioplasty.Org Interview Series: Transradial Approach
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Interview with Jack Hall, MD, FACC

Cardiologist Jack J. Hall, MD, FACC, is Program Director of the Care Group at St. Vincent's Heart Center in Indianapolis, Indiana -- a practice that traces its roots back to the beginnings of interventional cardiology in the U.S. and specifically Indiana, and to such early innovators as Cass Pinkerton and Thomas Linnemeier.

Dr. Hall himself has been a pioneer in the use of the transradial approach, having practiced it for over 15 years. Recognizing the need for training in this rapidly-spreading technique, Dr. Hall is one of the organizers of the Indianapolis Transradial Summit, being held on April 30, 2011, which will be focusing on will focus on presenting practical, straightforward information important in establishing or expanding a transradial practice. In this interview, Dr. Hall discusses the evolution of the transradial technique and its future implications for patient care and economic benefit in the U.S.

A complete list of educational offerings for the transradial approach can be found on the Transradial Training Courses page in Angioplasty.Org's Radial Access Center.



Jack J. Hall, MD, FACC
Jack J. Hall, MD, FACC

Q: Tell me about the upcoming Indianapolis Transradial Summit.
Dr. Hall: We're looking forward to advancing transradial technique out to more U.S. physicians, particularly here in the central Indiana region and the Midwest. We hope to bring in not only physicians and hospitals that want to start transradial programs, but also people that have adopted the technique recently and want to refine their technique with new tips and tricks. As a small deviation from our usual transradial training, we also want to offer transradial training to hospitals, hospital administrators, cath lab managers and CV service line administrators, such that they can learn along with their physicians about the transradial technique and what it may mean to their facility from an economic standpoint, patient throughput standpoint and, of course, help everyone to understand the clinical advantage of the transradial, and how patients certainly prefer it compared to the transfemoral approach.

"We've known for a long time...that vascular access complications result in not only morbidity and potential mortality for our patients, but a huge expense to our facilities and to our healthcare system as a whole. So any procedures that we can do that will limit our access site complication rate will not only be good for our patients clinically, but help our healthcare system..."    

Q: Your course is coming closely on the public conversations about Medicare cost-savings. What are the economic implications of moving to transradial: how can it affect the bottom line, both from reduced complications and increased efficiency?
Dr. Hall: The easy one is from complications. We've known for a long time, and anybody in the cardiovascular field understands, that vascular access complications result in not only morbidity and potential mortality for our patients, but a huge expense to our facilities and to our healthcare system as a whole. So any procedures that we can do that will limit our access site complication rate will not only be good for our patients clinically, but help our healthcare system which, I think we all agree, needs more help.

The other side of the equation is how does transradial help facilities from an economic standpoint? And the first big hump, as we discussed, was the decrease in morbidity and mortality from the complications of the vascular access. But we also have demonstrated, and many others have demonstrated, a lower cost of care because we're getting the patients up and mobilizing them so much faster so that they can be discharged from the facility much sooner than our previous attempts in the U.S. from the transfemoral approach. The use of [transfemoral] closure devices has not helped us from an economic standpoint. There are still many studies that demonstrate that closure devices don’t decrease the vascular access complication rates as low as we would like, and there are certainly added costs involved with vascular closure devices.

So if we can bring a patient in and do a transradial approach, have lower complication rates and be able to discharge that patient within a few hours of the procedure, that improves the throughput for the facility, decreases costs across the board. We also have demonstrated in our facility a decreased pharmacy cost in these patients. Not only are they not in the hospital as long, therefore they aren’t getting as many medications through our pharmacy, but also with the femoral approach we do manual compression often, and those patients receive more medications for anxiety and for discomfort, getting the sheath out and then they also frequently receive more pain medications while they're on bed rest, because most of our patients do have some discomfort from lying on their back for hours after the procedure.

Q: Angioplasty.Org’s patient Forums get patients writing in that they wind up with significant back problems from lying flat so long.
Dr. Hall: Absolutely. Anyone who's ever had any procedure, the bed rest is miserable. I've had knee surgery and understand some of those issues personally.

St. Vincent's Heart Center
St. Vincent's Heart Center,

Q: How long have you and St. Vincent's been offering the radial approach? How did it start and what challenges needed to be overcome?
Dr. Hall: I started doing transradial procedures in the mid-90s, around 1994. We brought it back and did our first 20 or so patients in a series and actually got that published in the American Journal of Cardiology in 1996. From then on we were convinced that patients really preferred the transradial approach.

We had some limitations during the mid-90s with equipment from a percutaneous revascularization standpoint, but certainly there were many patients that benefitted from our transradial approach due to body habitus issues or peripheral vascular disease.

One of the biggest categories is the patients who are anticoagulated with Coumadin or other anticoagulants who needed urgent or emergent procedures. With the low bleeding complication rates from a transradial approach, we felt very comfortable even early on in doing those patients from a transradial approach and have continued to utilize the technique in those patients. But as the equipment has improved, we've expanded our transradial approach to multiple interventions and complex interventions, as well as acute STEMI care.

Q: That was one of the interesting results from the RIVAL Trial presented this month at the ACC. There was a definite advantage for transradial in STEMI cases.
Dr. Hall: Certainly. I think that when you look back over the angioplasty history, and you know this better than most, Burt, our issues have always been that we know more anticoagulation, more blood thinners, more antiplatelet agents are better from an ischemic standpoint for our patients, but we also know that more blood thinners, more antiplatelet agents, etc. also increase our patients' risk for bleeding complications. Here now we have a technique that will limit the bleeding complications which should allow us to have more confidence to proceed on with more potent anticoagulants and get better ischemic outcomes.

Q: Dr. Mehta in Miami in his interview said the same thing: that perhaps the newest anticoagulant medications, bivalirudin in particular, with the transradial approach might be the way to move forward with STEMI patients.
Dr. Hall: Absolutely it's the way to go forward with STEMI patients. And on the other side of the coin I think Samir Pancholy recently demonstrated a case report of a patient who was at high risk for bleeding complications, so he used the transradial approach to decrease the vascular bleeding complications and then utilized bivalirudin to decrease the non-vascular access site bleeding complications. So it's kind of a two-pronged approach, depending on what patient population you're seeing at that time. It has a lot of advantages.

Q: Cardiologists in Europe and around the world look at articles published in the U.S. about transradial and they scratch their heads and say, "What's the big deal?" because they've been doing this for a long time. Now you've also been doing this since the very beginning of the wrist approach, so from your perspective, are things in the U.S. really beginning to change?
Dr. Hall: I think it's been a dramatic change since I started doing transradials. Early on in the U.S., doing a transradial procedure was almost heresy. Many of my colleagues would scoff at us; others would say what we were doing was malpractice, such that when we went to meetings and open forums, many of us did not even admit to doing transradials. There were very few of us early on: Matt Mick, Tift Mann, Dan McCormick. And it was great bumping into them at meetings and sharing stories about transradial, and learning from each other. But our ability to contact each other at that time was fairly limited.

We certainly didn't have all the technology that we have now for sharing cases and discussing with colleagues. So I found it really very rewarding over the last five years to be able to go to conferences and get information from other operators.

It used to be that I would see a transradial article, always from Europe or Canada, Gerald Barbeau et al, and read that with great vim and vigor, but then not have another transradial article come out in print for months. Now it's hard to pick up a journal without seeing something about transradial, and it's really adding to the body of the science and the information which will make us all better transradial operators.

    National Transradial Meeting
National Transradial Meeting

It's nice to see it's catching on because, as you pointed out, the United States is sorely behind in this technique, as compared to the rest of the world. Depending on whom you read, the U.S. penetration of 5% is woefully behind our European and Pacific Rim counterparts and I certainly don’t feel that they value their patient satisfaction and patient comfort more than us. I think we're just slower to adopt the technique and hopefully, with everyone's help, we're starting to make a dent in that and it's picking up momentum. It's very rewarding to see.

Q: One of the things that’s made it more popular is advances in the equipment, like needles and introducer sheaths and things like that. Things have gotten smaller. Does it need to get better?
Dr. Hall: Everything in cardiology needs to get better, but certainly industry and clinicians are driving to do that and we will continue to see improvements. In our initial transradial experience, the equipment we had was basically designed for the femoral approach and we had more spasm then, we had more complex cases, cases took longer. And then once we were able to get in, our ability to intervene in these patients was limited due to our guiding catheter size and the balloon and wire technologies. Now it is very easy both femorally and transradially to do interventions, to go through a 6F or a 5F guide, even complex procedures through these smaller guides is now more the mainstay. So as industry has continued to supply us with improved product we’ve been able to translate that into better clinical utility.

Q: It’s been said that the increased use of transradial and the motivation for cardiologists to learn the technique is going to be patient-driven, as people start to learn that they can get these procedures done with less pain, less morbidity, quicker recovery.
Dr. Hall: Early on in our experience we've known that patients really appreciated the transradial approach vs. the transfemoral approach. It was more comfortable for them, especially the early ambulation. They really preferred the transradial approach and once they had it done, they would request it. And the way we would build some of the practice was word-of-mouth. They would go to church or the grocery store or within their own family, such that people would be referred in because they knew we could do it transradially. Nowadays with the vast amount of information and access to the internet and sites such as Angioplasty.Org, patients can get volumes of information virtually with a few clicks of the mouse. So we're excited to see the American public becoming a better educated consumer of healthcare and will hopefully help drive the transradial technique as well.

Q: Where do you see things going in the immediate future?
Dr. Hall: I think that it is important in the United States with the changes in healthcare that we need, as physicians and clinicians, to partner with the hospitals and hospital administration, bringing in new technologies, new techniques, what have you. It really needs to be a joint venture. It is no longer just the patient and the doctor demanding this. We have to make sure we're doing the right thing short and long term from both a clinical standpoint but also a financial standpoint. I think that we're all feeling that pressure. Perhaps we're a little late and behind the curve in feeling that pressure compared to the rest of the world. But that's one of the focuses of the Transradial Summit that we're putting on in Indianapolis: to help hospital administrators understand this new technique, so that when a young physician comes back and says, "I want to do transradial," we hopefully will lower the barriers to adoption. The hospital administrator will say, "Yes. I've heard about that and understand the advantages to the patient and the advantages to my facilities. Let's work on this together and develop a multidisciplinary team approach, involving hospital staff, the clinicians, the patients as well as hospital administration.”

Along those lines I would also like to point out that, as you know, there are many industrial companies out there with transradial products. But quite frankly, the profit margins on these small products are fairly small. We aren't talking about drug-eluting stents or new hip prostheses, or percutaneous aortic valves – these transradial items are fairly low profit things, yet industry has been very supportive of transradial. They are very excited at assisting us from an educational standpoint and getting the word out, and supporting our educational symposia, even though it might not translate into selling more products for them. And I think that we often malign industry and give them a bad rap. I think that this is a case where industry is going above and beyond in helping with educational support and they need a pat on the back because I think they deserve it.

This interview was conducted in April 2011 by Burt Cohen of Angioplasty.Org.