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R. Lee Jobe MD

As part of its ongoing series of interviews with physicians who practice the transradial approach for angiography and angioplasty, Angioplasty.Org recently talked with R. Lee Jobe, MD, Chairman of Invasive Cardiology at Wake Medical Center in Raleigh, North Carolina.

In this interview Angioplasty.Org discusses with Dr. Jobe why the the transradial approach is under-utilized in the U.S. and how it can lower complications and increase patient satisfaction. For more about what the transradial approach, visit our Radial Access Center.

Q: For most patients in the U.S., catheter access for an angiogram or angioplasty is done through the femoral artery in the groin. What is radial access or the transradial approach, using the radial artery in the forearm?
Dr. Jobe: The transradial approach is an alternative access to the coronaries, from the radial artery rather than the traditional femoral artery. We have developed and used transradial access to try to reduce the complications and improve patient satisfaction with the procedure.



R. Lee Jobe MD
Dr. R. Lee Jobe
of Wake Medical Center
Raleigh, North Carolina

Q: What are the complications in the femoral approach that are being reduced?
Dr. Jobe: From the femoral access, we run into problems with bleeding, both from the artery out to the skin, and from the artery backwards into the retroperitoneal space, because the femoral artery, depending on where exactly the needle stick into the artery is, is not easily compressible when we pull the sheaths and catheters out. In addition, some people tend to carry a little extra weight down around their waist and thighs, and there can be a significant amount of extra body tissue overlying the femoral artery, making it deeper and more difficult to gain control of the artery for pressure when you pull the catheter out.

The radial artery is just underneath the surface of the skin in virtually everybody, and is easily accessible with catheters. The radial access is easily compressible with fingers or any of several support devices that are available.

The other advantage that we look at is that people who have had femoral artery access often are limited to bed rest for somewhere between two to six hours after the procedure. From the radial access, patients are literally ambulatory immediately. So there's none of the discomfort or complications that are associated with the prolonged bed rest after femoral access.

Q: Are there other complications, besides bleeding, that are lessened by using the radial approach?
Dr. Jobe: Most all of them are bleeding-related in one way or another, either hematoma, femoral artery pseudoaneurysm, arterial venous fistula between the femoral artery and femoral vein, and retroperitoneal bleeding. In some of the larger patients, there's also a risk of cellulitis or skin infection from femoral access. There's virtually no risk of cellulitis or skin infection from radial access,

Q: We get patients writing into our Forum who have had femoral access and have wound up with some level of disability post-procedure. They find that their leg is weak, they're limping, and they've been diagnosed with some sort of nerve trauma or nerve damage that has occurred.
Dr. Jobe: Well, the femoral nerve does lie right beside the femoral artery, and it is possible to damage the femoral nerve either transiently or permanently with catheter access. In addition, the femoral artery is the largest and essentially sole blood supply down to the leg. So, if a clot were to form in the femoral artery at the catheter site and travel down the leg, there could be a significant ischemic problem in the leg from embolization.

By the nature of the patients that we select for radial artery access, there's dual blood supply to the hand through the ulnar artery, which we carefully look for and document. By this dual blood supply, even if the radial artery is totally occluded after our procedure, there will be no distal vascular complications, because the hand is protected by the ulnar artery.

Q: Femoral artery complications are quoted at around 3%, but most cardiologists we've spoken to agree that it's higher, if you take into account what are considered “minor” complications. Are complications really lower with radial access, or is it just a different kind of complication that occurs?
Dr. Jobe: Oh, it's substantially lower than that. With radial access, we do several hundred cases a year here at our institution, and our complication rate would easily be less than one half of one percent.

Q: What is the percentage of cases that you do radially?
Dr. Jobe: I do about 1,200-1,300 diagnostic procedures a year. I do approximately 400-420 interventions a year. 50-60% of those would be radial, including the diagnostic.

Q: Some cardiologists assume that you do radial only when you can't do femoral -- for reasons of obesity, or where there's disease in the femoral artery. Is that the way you approach it?
Dr. Jobe: No. Actually, what we're finding is that, rather than viewing radial access as a bail-out when the femoral won't work, the better approach is to look at the radial access as the primary access point, and use the femoral only when the radial is contraindicated. So, I think it just takes a little bit of change of mind set. Rather than looking at the radial as the backup access, look at it as the primary access, and then use the femoral as your fallback approach.


Q: When you look at a patient, how do you judge whether they are candidates for radial access?
Dr. Jobe: We test for collateral blood flow to the hand. The hand has dual blood supply beginning just below the brachial artery where it bifurcates into the radial and the ulnar arteries. They meet in the palm or arch in the hand. So, what we have to see before we think a patient is a candidate for radial access procedures is that there's adequate flow down the ulnar artery, and that it goes through the palm or arch, completely all the way around to the thumb.

The basic test is some version of the Allen test. We occlude both the radial and ulnar artery. We'll see that the hand will blanch completely, and then we release the ulnar artery, and through one mechanism or another -- either visual assessment of the return of blood flow to the hand, or pulse oximetry on the thumb -- we will document that there is complete collateral circulation to the entire hand through the ulnar artery only.

Q: What are the cases in which you don't do radial as primary?
Dr. Jobe: If there's not collateral circulation to the hand, we won't go radial. We also find that many patients who have had previous coronary artery bypass grafting are not optimally done via the radial approach, especially patients who have had the left internal mammary graft utilized.

Q: The radial approach has been around 15 years or so, but in the U.S. patients don’t hear about it very much. Is it that there’s resistance to it in the U.S.?
Dr. Jobe: In the Netherlands, the penetration for radial procedures is approximately 2/3 of the procedures done. In France, 30-40% of all procedures are done radially. In Japan, the penetration is similar, approximately 40%. And in the United States, when we poll our interventional cardiologists we find that it’s less than 2%.

I don’t think it’s resistance, I think it’s lack of motivation to acquire the procedure. In European and Asian centers, physicians and hospitals are not limited by reimbursement. If they can do an intervention successfully and have the patient be ambulatory, those patients can be discharged and go home the same day. With the femoral approach, it is virtually contraindicated to send the patient home the same day, regardless of whether any femoral-type closure device is used. But with the radial access we literally can ambulate the patients immediately [allow them to stand up and walk]. Discharging them several hours later is not a problem.

But in the United States current Medicare/Medicaid reimbursement actually penalizes the hospital if a procedure is designated as an in-patient procedure, which coronary stenting is, and if the patient is sent them home the same day as an out-patient -- the hospital is actually penalized for that rather than rewarded. So there has not been a financial incentive for people in the United States to pick up the procedure. I think if it were reimbursed equally as an out-patient or ambulatory procedure, hospitals would strongly encourage their physicians to do it because a certain number of patients who have coronary interventions done could be done as out-patients and discharged home the same day, which would free up hospital beds.

Q: So you’re saying that one of the big reasons for keeping patients overnight has little to do with their heart disease – it has to do with the healing of the femoral artery puncture that is made for catheter access?
Dr. Jobe: Right exactly.

Q: Do you see the reimbursement issue changing?
Dr. Jobe: I do. CMS is, of course, accepting proposals for getting changes to their reimbursement models that may help them save money. We have written them a proposal to use our institution as a demonstration site for ambulatory coronary stenting from the transradial approach. Under the demonstration site protocol, the hospital would not be penalized for doing these patients as out-patients and through a program like this we could demonstrate to CMS that selected transradial coronary interventions could actually end up saving the health care system significant amounts of money by allowing us to do patients as out-patients.

Q: In your own practice in North Carolina, what have been the major advantages of using the radial approach?
Dr. Jobe: Primarily, the reduced risk of femoral bleeding complications -- the reduced risk of vascular complications, including distal embolic events. But the primary thing that really drives this for us is increased patient satisfaction. They find that it’s so much more comfortable to be able to sit up in a chair immediately following their procedure.

When they’ve had femoral access, they’re restricted to bed rest for 4-6 hours because of the risk of bleeding from the femoral artery, and if they need to use the bathroom they’re restricted to bed pans.

But from the radial approach, they’re up and ambulatory immediately. They can sit up, they can eat, they can go to the bathroom normally, if they have problems with chronic back pain or muscular skeletal disorders, they can work with those immediately. We just find that once a patient has had a radial access procedure, they really don’t ever want us to go back to the femoral again.

    Dr. Jobe in the cath lab
Dr. Jobe in the cath lab

From a physician’s standpoint, we find that it’s a unique calling card that separates us. We think that it helps give us a little bit of a competitive advantage, because we are the only group here doing a significant number of radial access procedures. And our patients like to go back home and talk to their friends and family and when they say they’ve had their catheterization procedure done, they point to their wrist and they say, “Oh, it was Dr. Jobe or it was Dr. Mann”, and it’s just one more thing to talk about, one more thing that gets our name thought of a little more frequently. It’s just one more feature that makes our practice unique and memorable, both to our patients and to our referring physicians.

Wake Medical Center
Wake Medical Center, Raleigh, North Carolina



Q: How did you get involved in this? When did you do your first radial procedure?
Dr. Jobe: Dr. Tift Mann, here at Wake Heart, is one of the major proponents of transradial procedure. He learned directly from Dr. Kiemeneij in Amsterdam, and as soon as I joined Wake Heart, within the first week I was doing transradial procedures as well, as soon as Dr. Mann showed me the technique.

Q: That brings me to training. You learned in a one-on-one mentoring situation. Today how would a cardiologist who doesn’t do radial go about learning how to do it, what is the learning curve?
Dr. Jobe: I’m glad you brought up learning curve, because there is a learning curve to the procedure. We think it’s important that the first 100-125 patients people select, when they’re going to bring transradial to their practice, be patients who are likely to be easy transradial cases. Middle-aged men with large radial arteries make very easy transradial access. We find that elderly patients, especially elderly women, are very likely to have tortuous subclavian, tortuous innominate arteries, and tortuous ascending aortas. And patients who are short tend to have very short ascending aortas. Those are some things that make the access a little more challenging, and those types of patients should perhaps be reserved for later on in somebody’s experience.

We think the way to gain experience is a three-pronged approach: first, attending one of several training sessions that are sponsored at several hospitals throughout the United States; then, a couple of companies have developed computerized simulators where the physical approach to transradial, manipulating catheter, catheter selection, accessing the radial artery, can be practiced in a simulator setting, is important; third is to have a mentoring process. They should invite somebody who’s very experienced to come to their center and spend a day or two with them while they’re doing their own cases in their own center, and offer advice and critique the technique within their own hospital.

Q: Is there a problem using any devices with the radial approach?
Dr. Jobe: We typically use 6F catheters, and anything that can fit through a 6F catheter will work via the radial access. We’ve used rotablators, up to a 1.5mm burr. IVUS can be successfully done through the radial, AngioJet rheolytic thrombolysis can be done through the radial. We find that kissing balloon, kissing stent techniques all can be done through the transradial with 6F catheters quite successfully. You cannot put in a balloon pump from the radial access, so that is pretty much the absolute contraindication.

Q: If you’re just doing diagnostic caths, can’t you do these as outpatients, even with the femoral approach?
Dr. Jobe: Yes. But in the femoral approach, if we’re going to try to send them home the same day, most of the time we’ll use some form of closure device, and the closure devices, of course, have their own complications associated with them including infection, including embolization of the closure device material, including occlusion of side branches. There is no closure device needed with transradial.

Q: How does it work when you pull the sheath out?
Dr. Jobe: We pull the sheath out when we’re done, regardless of the level of anticoagulation, and we use a radial artery support device. So we find that, for example, if we have an emergency coming from the emergency department or transferred in from an outside hospital, who maybe has received full thrombolytic therapy, or is aggressively anticoagulated with heparin and a IIb/IIIa inhibitor, we specifically look at those patients for transradial access just because the bleeding complications from the access site will be lower.

Q: How quickly are you able to achieve hemostasis and stop bleeding?
Dr. Jobe: In diagnostic catheterizations where we do not provide significant anticoagulation, we’ll maintain pressure with a radial artery support device for 20-30 minutes. Then it’ll be loosened and removed.

In a fully anticoagulated intervention, we’ll leave the device on for about an hour before we start loosening it and removing it. And we have all of our staff well in-serviced on how to assess the radial artery for adequate hemostasis.

Q: And all this time the patient is still ambulatory?
Dr. Jobe: Right. Our transradial recovery area doesn’t have stretchers, it’s got chairs!

Q: So to sum up the major advantages of the radial approach?
Dr. Jobe: I think the major selling points on transradial and the reason that we believe it in so much are the virtual elimination of vascular complications, the increased patient comfort and satisfaction associated with it.

This interview was conducted in July 2007 by Burt Cohen of Angioplasty.Org.

Radial Recovery Area at Wake Medical Center