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Angioplasty.Org Interview Series: Transradial Approach
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Interview with Mehrdad Saririan, MD

Having learned the transradial access technique as a fellow in Canada, Dr. Mehrdad Saririan brought this experience with him to the Lahey Clinic in Boston, where he completed his interventional fellowship and, as he relates, "my passion for radial catheterization and the perceived novelty of the technique earned me the nickname of radial man." Dr. Saririan lectured and taught transradial intervention to the physicians at Lahey and initiated their radial program, which is now the largest in Massachusetts.

Dr. Saririan moved to Phoenix and is now the Director of the Cardiac Catheterization Lab at Maricopa Medical Center, the largest teaching hospital in the Phoenix metro area. A self-confessed radial evangelist, Saririan taught the technique to his division chief, Dr. Jay Kaufman, and together they currently perform over 80% of their cases from the wrist. They will also be teaching a one-day course in the radial technique at Maricopa, on December 5, 2008 (see more information the course and registering).

For more about the transradial approach, visit our Radial Access Center.



Mehrdad Saririan, MD
Maricopa Medical Center
Phoenix, Arizona

Mehrdad Saririan, MD
Dr. Mehrdad Saririan

Q: When did you first start using the radial approach?
Dr. Saririan: Radial procedures were commonplace when I was a trainee and cardiology fellow. Where I started my cath lab rotation, people were doing radial procedures routinely, so it wasn’t something novel; it was routine. I trained with radial puncture as being first line access, so for me it was the norm. I learned the technique at McGill University in Montreal, Canada and my mentor, Dr. Jean-Pierre Beaudry, was kind enough to let me do the radial punctures. It wasn't anything special. It wasn't a novel idea. It was how we did things. And that's how I learned the radial technique. Afterwards I went on to the Montreal Heart Institute where I did my first year of interventional fellowship and that's when we did more and more and that’s where I learned my radial interventional skills, as opposed to just angiography skills. Montreal Heart Institute is where the first radial procedure was described by Dr. Campeau back in '89, so it was a fitting place to learn the technique.

Q: Radial access is more popular in Canada and other countries than in the U.S? Why?
Dr. Saririan: Radial catheterization is not the norm in Canada either, but there is a higher majority of interventionalists that practice the approach there than here in the United States. I think that the number one driving force for adopting the radial procedure in Canada is cost. Because Canada has socialized healthcare, cost is always an issue. There's less cost associated with a radial hemostasis device than with a femoral vascular closure device. Also from the arm it's very easy to engage both coronaries with a single multipurpose diagnostic catheter, so that’s another way that costs are decreased, by using a single multipurpose catheter. And there's less cost in terms of hospitalization and complications. So I think part of the reason why radial procedures are common in Canada is because of the necessity to contain costs associated with this procedure.

Also, once that has been established and referring physicians have caught onto the idea, they are now requesting it more and more commonly. A friend of mine who's at the Jewish General Hospital in Montreal told me, “If you're not doing radial procedures, you're not going to get referrals.” So referring cardiologists are now expecting that their patients be done radially, because the patients are so much happier when the procedure is done that way.

Q: Have you experienced this advantage, where patients prefer to come to a radial center?
Dr. Saririan: I initially started my career in Phoenix in private practice and it was a huge competitive advantage for me. I had a lot of referrals from competing interventional cardiologists because of patients who were obese and the referring cardiologist could not do the procedure femorally. For a few patients I had them referred to me directly for a radial procedure. Oftentimes I would scrub in with the interventional cardiologist and teach them how to do the procedure themselves. But in the past year-and-a-half, I have left private practice and I have joined the county hospital here in Phoenix and this is a closed system and we don’t make much noise. But we use radial as our first line access, and do 80% of our cases from the wrist. I stopped counting after I had done 1,000 cases this way.

Q: Cardiologists who are "femoralists" still look suspiciously at the radial technique and claim that you can run into problems with trauma, needing a larger artery to do certain procedures, etc.
Dr. Saririan: These are criticisms that are very common. The common objection that I have heard to the radial procedure is the learning curve: if you don't learn radial during your interventional training, then once you're out in private practice, it becomes difficult to pick up. So that's the first common objection. Another is that you're going to traumatize the radial artery. There is a small incidence of radial artery occlusion. My answer to the trauma aspect is: (a) surgeons use the radial artery for grafts, so obviously the hand can do without the radial artery, if the Allen's test is normal, and (b) even if you traumatize the radial artery, and the radial artery occludes, if the patient has a normal Allen's test, all studies have shown so far that the incidence of radial artery occlusion is completely clinically silent. So, I think that argument is overblown.

A third objection is that you can't do procedures which require higher French sizes. Again the common answer to that objection is that 95% of the techniques we use in the cath lab require only a 6F sheath. It's rare that we need to upsize to 8F sheaths nowadays. Stent technology, wire technology, everything has been miniaturized. We can do kissing balloons through 6F sheaths; we can do rotational atherectomies through 6F sheaths; we can do AngioJet through 6F sheaths. So I think that's a non-argument. That may have been true in the old days when everyone would use 8F sheaths for routine interventions, but that's not the case anymore. We know that higher sheath sizes are associated with higher bleeding complications. So I would not know why one would want to upsize to an 8F sheath anyway. You're just going increase your bleeding complications. The vast majority of things can be done through a 6F sheath.

The final common objection that I've heard is the availability of femoral vascular closure devices. They say, “Well, I can use an AngioSeal and my patients are up in two hours and I don't have any bleeding complications.” But if you look at the actual meta-analyses of all the femoral closure devices that have been studied and compare that to manual compression, the only thing that closure devices have been proven to do well, is to decrease the time to ambulation. There's not one study that has definitively proven that closure devices actually decrease bleeding complications and bleeding rates, compared to manual compression. So with that in mind, I think the radial approach far surpasses the femoral approach in terms of all these complications and all these objections.

Q: Dr, Sunil Rao observed in his recent study that the NCDR data seem to show a spike in the use of radial in the U.S. in the last quarter of 2007, although the usage is still in very low single digits.
Dr. Saririan: I think the reasons for it have been driven by recent studies associating bleeding and mortality. The radial proponents have been trying for more adoption of this procedure ever since it was developed in the 90's, except our voices had always been quieted down because of lack of industry support, because of lack of support in the national guidelines. Finally we're having people, such as Dr. Jeff Popma and Dr. Gregg Stone, coming out and saying, “Hey listen -- bleeding is bad and, if there's a way that we can decrease it beyond pharmacologic means, we should adopt it.” I think industry finally is getting on board. I think soon it will make national guidelines. I think third-party payers will finally catch up to this and say. “Hey this benefits my patients. I will reimburse you more if you do a radial technique than if you do a femoral technique.”

There are a lot more training programs now, so I'm hopeful that in the next few years the radial access technique will at least surpass 10% in the NCDR data.

Q: Speaking of training, you have a course coming up on December 5, 2008.
Dr. Saririan: There are a lot of myths surrounding radial procedures. And I think a course like ours that can try to debunk some of these myths is very important. So if you can have a sit-down with a person who does large volume of radial PCIs and you go over some of the tips and tricks of the technique and you try to debunk some of these myths associated with radial catheterization, that’s very important. Simulation training is also very helpful. It's obviously not as good as having practice on live patients, but it is the second-best thing, so I think simulation training is very useful and we are incorporating that into our course.

    Maricopa Medical Center
Maricopa Medical Center
Phoenix, Arizona

Finally live case demonstrations. In our first course, our physician trainees won't actually be scrubbing in, but they at least will be able to be in the cath lab, watching as things are being done and they'll be able to ask questions as they are occurring. So I think those three components are very important: a sit down didactic teaching session going though some of the tips and tricks, simulation and finally live observation. In the future we are hoping to include a practical component, where you would come here and actually do a procedure, but there are some hurdles with respect in terms of malpractice insurance, etc., but I'm hoping we can overcome those.

Q: You've mentioned reimbursement. Is this something that's going to become more important in the next year or two, because of the changes that are going to be happening in the field of healthcare?
Dr. Saririan: I think we're going to see pay-for-performance and pay-for-quality measures -- that goes without saying. Anything that you can do to decrease hospitalization costs and decrease complications should be encouraged and should be reimbursed accordingly. So that's why I think that the radial technique should become more and more routine and established here in the U.S., especially with these proven changes in how medical procedures will be reimbursed. It's only common sense.

Q: We've discussed some of these, but what are the specific areas where radial can reduce the costs of an angioplasty?
Dr. Saririan: First thing is bleeding complication rates. No patient has ever died from a retroperitoneal bleed from a radial puncture. That's something that can clearly prolong hospitalization stay. There's less cost associated with transfusions. There's less cost associated with imaging techniques in order to diagnose the bleeding whether it be ultrasound or CT. There are fewer costs associated with femoral closure devices. And I think soon we will see a change in reimbursement rates such that we will outpatient PCIs. Patients will not stay in hospital overnight. They will be able to go home early. And the hospital and physician will still be reimbursed the same way. At least I hope that's what's going to happen. So, in all those ways, less hospital stay, no overnight hospital stay and no bleeding complications, no CT, no ultrasound, no vascular closure devices -- in all those ways, I think you can reduce your costs associated with this procedure.

Q: What about complications from the radial? Some patients have written into our Forum that when they leave the hospital their arm is sore and they feel a discomfort in their arm. Does this go away?
Dr. Saririan: In respect to the discomfort in the arm, I also think a lot of femoral patients complain of discomfort in their groin. The fact that you puncture an artery and you have a vascular hemostasis device that's applied over the artery, for a small period of time, I should think that one should expect to have a sore wrist at least initially, maybe for the first day or so. But it's not been my experience where patients have had chronic arm pain because of the radial puncture.

Other potential complications are radial thrombosis or radial occlusion -- but all of the studies that have been done so far have shown that this is usually clinically silent. Bleeding complications are virtually non-existent. The most I have seen is a mid-forearm hematoma due to aggressive wiring techniques, which is part of the tips and tricks that a physician needs to learn when they are learning radial procedures. That's rare and usually can easily be taken care of by an ACE bandage. Bruising is common but it's not considered a major bleeding complication.

Q: What currently is the role of the device manufacturers in terms of the advances in equipment for the radial approach?
Dr. Saririan: The role of the equipment manufacturers has been key in establishing the radial technique. Had it not been for the better wires, the more deliverable balloons, the more deliverable stents, I do not think that we would have been able to do routine radial procedures as we do now. It's only because we can do 90+% of the current interventional techniques through a 6F guide that we are able to do radial procedures today. The fact that stents are more deliverable and the fact that the thrombectomy devices and distal protection devices can be done through 6F sheaths are all reasons why radial procedures have been adopted at least the world over, if not in the United States.

Q: What is the role of the professional societies?
Dr. Saririan: If the societies and the well-known experts in the field of interventional cardiology don't come out and promote this idea it won't be adopted as a matter of routine. So the societies will play a major role in pushing interventional cardiologists and training programs to adopt the radial technique.

But until and unless it makes it into the guidelines as a Class 1 or at least a Class 2A, I don't see it as becoming more common than a few niche practitioners here and there. So the TCT, the ACC and the i2 summit, the SCAI will play huge roles in promoting this technique. I think it's coming. Clearly, as you said, the NCDR data shows a spike in the last quarter of 2007 – and that's because a lot of these publications that are coming out with respect to bleeding mortality and people are waking up to the fact that bleeding is bad and, if there's a way to reduce this from a radial puncture, then it should be adopted as a matter for patients’ safety sake. So those societies will play a huge role and I think it's going to make it to the guidelines if not in the next revision, then the one after.

Q: Dr. Saririan, thank you for your time. I’m sure your thoughts and experiences will be helpful to the readers who visit Angioplasty.Org 100,000 times a month.
Dr. Saririan: You’re welcome. I think your site is the only one that's promoting the radial technique in the U.S., so I commend you and your website for creating such an avenue for physicians to educate themselves. There's no other site that's doing this as well as you guys are doing it. I think people who want to learn the radial technique will need to log on to your website.

Registration for Dr. Saririan's Transradial Access Training Program in Phoenix is currently open, but there are only a few spaces left. More information can be found here.


This interview was conducted in November 2008 by Burt Cohen of Angioplasty.Org.