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As part of its continuing
series of interviews with physicians who practice the transradial
approach for angiography and angioplasty, Angioplasty.Org
recently talked with Jeffrey J. Popma, M.D. of St. Elizabeth's
Hospital in Boston.
Dr. Popma has published more than 280 peer-reviewed manuscripts
in the field of interventional cardiology and regularly
speaks at major cardiology meetings worldwide. Dr. Popma
has served as the past-president of the Society for Cardiac
Angiography and Interventions (SCAI) and currently serves
as chairman of the American College of Cardiology Cardiac
Catheterization
Committee and Ad Hoc Committee on Simulation Training.
Previously at Brigham and Women's Hospital in Boston, he
recently joined the Caritas Christi Heath Care System where
he heads
the invasive cardiology program and serves
as Director of the Cardiac Catherization laboratory at
St. Elizabeth's.
In this interview Dr. Popma discusses expanding the radial
program in his hospital, the training and changes needed
in the cath lab to institute such a program, and how using
the transradial approach can reduce the types
of complications seen with the femoral (groin)
approach. For more about what the transradial approach,
visit our Radial
Access Center.
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Dr. Jeffrey
J. Popma of
St. Elizabeth's Hospital
in Boston, Massacusetts |
Q: How and why did you start doing radial access
cases?
Dr. Popma: While I was at the Brigham and Women’s Hospital,
two of my former partners there, Dan Simon and Campbell Rodgers,
trained with Gérald Barbeau, who is one of the world's experts
in the radial technique, and they brought that back to the Brigham.
And it was pretty clear that they were able to do some very difficult
patients with relative ease by moving over to this alternative
access. The access is easy, the bleeding is extremely low. The
patients are able to ambulate, to sit up in a chair, immediately
afterwards. In the vast majority of patients, the coronary arteriography
can be done as quickly as with the femoral approach.
So they brought the technique back, and then I learned it, and
it was something that really did make a huge difference in patients,
and particularly with referral patients. When patients would hear
that one could go from the wrist rather than from the leg, that
was something that they wanted to do, and in some subsets of patients,
particularly those who were markedly overweight, or those patients
who had severe peripheral vascular disease, precluding use of the
femoral approach, it was really the only way that heart catheterization
would be performed. So I actually learned my early skills in radial
approach at the Brigham, more out of necessity to compete with
my partners, but really it became something that was a very important
part of my armamentarium.
Q: Estimates are that 30-40% of the cases in the Netherlands,
France, Japan, etc. are done from the wrist. In this country it's
less than 5%. Why is that and do you see the situation changing?
Dr. Popma: The radial approach is one that's more popular in Europe,
partly because it does require a shift in the entire delivery of
care. So the nursing care, both before and after, is different.
The routine requirement to assess the radial artery pulse, using
an Allen test, is something that patients and nurses need to become
familiar with. Also the physical setup in the cath lab is different,
in terms of how the patient is positioned for the procedure, and
how the patient’s arm is positioned. The IV access is different.
After the procedure, rather than there being attention on the groin
management, it's that you really need to have more chairs, so patients
can actually sit up a little bit afterwards.
So, I think the reason it has not become more popular in the United
States is that many of the pieces required to have a very active
and good radial program require not just that the doctor changes
the technique, but that both the nurses and support staff change
the technique. In some pocketed areas, it's extremely popular,
and patients have the majority of their procedures done in this
fashion. In other places, where you may be dealing with 50 or 60
busy practitioners, it may not be as easy to make that shift for
the 1 or 2 practitioners who want to do the radial approach.
Q: How does one go about training?
Let’s
say I'm a cardiologist. I don't know the radial approach. I've
done femoral all my career,
but I'm interested in this. What do I do?
Dr. Popma: Well, first, there's the didactic piece. And then there's
a new textbook in radial artery angiography and intervention by
Dr. Tejas Patel that's extremely useful for every different type
of anatomy that one may come up with. So certainly familiarity
with the literature, and with the teaching materials, is important.
The second piece is that one has to train, and certainly at all
the major meetings now there are simulators, to simulate both the
arterial access, as well as to navigate some of the tortuous anatomy
that occurs in the radial artery and the brachial artery. So training
on a simulator is a good next step. Finally, I think probably the
most important one is to have a good proctor. And one can either
go to a site that has a very, very active program, or a proctor
can come to your site, and you can tee up 5, 6, 7 cases to kind
of get the adequate skills.
Having said all of this about the training piece of it, once you
figure out the arterial access, and some basic fundamentals about
the catheter manipulation in the aorta, you're pretty much off
and running, and can pretty much do it. And that really becomes
a piece of practice where you actually start out doing some routine
cases, and then move into some cases that are not quite so easy,
those with peripheral vascular disease who have also have concomitant
aorta disease.
So, really, several levels: first, learning the didactic; second,
simulators are very helpful; and third, the mentoring and proctorship
is an important component. But really, most of the learning comes
by doing.
Q: What percentage of your cases, both diagnostic and PCI, do
you do radially?
Dr. Popma: I'm probably right now at 10-20%, where I do them when
I have a clear indication: a patient who may be overweight, or
have peripheral vascular disease. But I think it's certainly an
area where we can expand more, and will be expanding more as we're
thinking about how we're going to restructure some of our cath
lab operations here at St. Elizabeth’s Hospital to allow
this to happen more easily.
Q: What are the advantages of the transradial approach for the
physician?
Dr. Popma: I think the advantage is not worrying about groin complications.
One of the things we all worry about when we do a case is getting
in and getting out of the access without having a complication.
Certainly not having groin complications is a very, very needed
adjunct benefit. But I think the patients also like it. And I think
they like it because of the comfort of the procedure, and the fact
that they get ambulatory a little bit earlier.
Q: Angioplasty.Org hosts a Forum
Topic about complications from the femoral access site and
we're kind
of amazed at the number
of postings. Sometimes the complications are minor, but some can
really affect patients’ ability to lead an active life. I've
seen femoral access complication rates quoted at 2-3% -- most cardiologists
think it's double that when you factor in all these “minor” complications.
How does the radial approach compare?
Dr. Popma: Oh, I think radial vascular complication rates are under
one percent. I mean, if you do an appropriate Allen’s test,
even if you occlude the radial artery, the chance of having a significant
limb ischemic complication is very, very low. On a very, very rare
occasion-- a one out of a thousand cases – there may be difficulties
removing the sheath from the vessel, and that's certainly been
reduced substantially when we use hydrophilic sheaths. But that
really is much less when compared to the femoral complication rate.
The femoral complication rate is probably, if we're honest about
things, between 3-5%.
Q: What about nerve damage with the groin approach? Where nerves
get pinched or perhaps dinged a little.
Dr. Popma: That's a good point, and not necessarily just when going
in. Sometimes you have to use an additional Femstop or some other
compression device, and that does have a higher rate of nerve injury
or nerve damage. I have not had a case where a similar sort of
thing has happened from the radial approach. I think that there
just are no major nerve beds that are in that direct proximity
to the radial artery that could be easily damaged.
Q: Would you use the radial approach on someone who had to use
their hands all the time, for example a musician, or a surgeon?
Dr. Popma: I think that's a great question. I think that if you
used your right hand all the time, if you were a tennis player,
or a pianist, or a musician or maybe a surgeon, the number of times
that you'd ever have significant, real significant injury to the
limb is just exceedingly low. But there may be some hematoma, little
blood blister that it needs to heal beneath the skin, that may
cause some soreness, so I probably would shy away from it personally,
if somebody really needed their right hand, or their left hand,
very actively.
Q: Which hand do you normally use for access?
Dr. Popma: You can go either way. Typically we go from the right
arm, because at some point the cardiac surgeons might want to
use the left radial artery for a bypass surgery. So, we try to
keep that pristine and pure. Typically we use the right arm,
the right wrist. But, if we're doing a heart catheterization
on somebody who's had prior bypass surgery, then it's really
much easier to go from the left side, if they still have a patent
radial artery, because that way you can get the internal mammary
artery on the way down.
Q: Is there any equipment that you can't deliver because the radial
is a smaller artery?
Dr. Popma: We’re a little limited by the size of the catheter,
where we can actually go up to an 8F or 9F catheter fairly freely
in the femoral artery. In the radial approach, for women, it’s
6F and sometimes 7F. For men, 7F -- sometimes you can squeeze an
8F catheter in, but he'd have to be a relatively large man. Now,
with our current stenting becoming much more freely performed with
smaller guiding catheters, it's less of an issue. Because we can
do stenting, even where it's simultaneous kissing stenting, through
a 7F guiding catheter, where in previous days, you might have needed
an 8F or 9F catheter. So, there's been some miniaturization of
the equipment so we can actually perform it through smaller catheters.
Q: At the end of the procedure,, when you pull the sheath out,
what is the protocol?
Dr. Popma: There’re a number of different compression devices
that can be used to pull it out, or you can do something very,
very simple, like just a gauze pad and a little plastic clamp that
holds the pressure of the gauze pad against the radial artery while
it clots off. Usually it stays on for a couple of hours or so.
There are also a number of devices, Terumo makes one, of course,
where there's actually a compression of the radial artery itself.
Q: Are there cost-savings to performing
radial? It’s my
understanding that the way reimbursement in the U.S. works, the
potential savings for same-day discharge are not being realized.
Dr. Popma: Certainly if anybody's going to have a same-day discharge,
it's going to be a patient who has had a radial artery access.
That why it makes sense: because they can ambulate and you don't
need to worry about groin complications. But you're right, we've
really had a hard time recouping the cost savings other than the
fact that about 90% of patients now seem to get a vascular closure
device. And so you save the money on the closure device, because
you don’t use one – all you really need is direct compression.
St. Elizabeth's
Hospital
Boston, Massachusetts |
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Q: Do you see a
point where you'll be looking at radial as your preferred
first tier approach and, if a patient’s not applicable,
then you’ll do the femoral?
Dr. Popma: Personally, I think we have a very heterogeneous
practice population at the place where I work and I think more
regular use is certainly a good thing. There's just some times
when the patient population is just not perfect for it. I know
some skilled practitioners can say they do 90% of their cases
from the radial. And I think that that's great. I think sometimes
the radial artery can be a little bit small for my taste, particularly
in elderly women. And then the femoral approach is a little bit
safer, to make sure that we don't cause any disruption of the
artery. And some patients just don't have a normal Allen’s
test. So they've already developed some radial artery disease
that is precluding use of that approach. |
Q: How has the ability to do radial impacted your practice?
Dr. Popma: One of my partners is a very active radial guy -- he
does about 50-60% of his cases from the radial approach, including
acute myocardial infarctions. So the only thing we spat about
right now is what the best adjunct devices are, what our favorite
sheaths are and what our favorite clamp devices are to compress
the artery afterwards. It's never anything about whether or not
it's a good technique. In fact it is a great technique. What
we'd really like to do is figure out what the best products are.
Q: Are you finding that patients come to you knowing you do radial?
Dr. Popma: Not quite yet, we've haven't fully gotten the word out
for that yet. But we hope to do that over time. I think patients
will really flock to the physicians who do the most procedures
and have the best outcomes. That's really what they flock towards.
And I think that this will certainly be one of the reasons why
they're going to want to flock. I mean, it's much quicker to
get in and up after the procedure, and going from the wrist is
sure preferable to the leg, particularly in patients who have
a little bit of extra weight, where it's going to be difficult
to make sure that they lie flat afterwards.
This interview was conducted in July 2007
by Burt Cohen of Angioplasty.Org.
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