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Angioplasty.Org Interview Series: Transradial Approach
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Richard R. Heuser, MD

Dr. Heuser of the Phoenix Heart Center serves as Chief of Cardiology at St. Luke’s Hospital and Medical Center in Phoenix, Arizona. Dr. Heuser is an internationally-recognized cardiologist, inventor, educator and author, and one of the early pioneers of angioplasty. A diplomate of the American Board of Cardiovascular Diseases and American Board of Interventional Cardiology, he has more than 30 years of private practice, medical administration and clinical teaching experience.

With 13 patents granted for different catheters, stents and other medical devices, and several more patents pending, Dr. Heuser has served as principal investigator to research the safety and/or effectiveness of more than 100 medical devices and more than 70 pharmaceutical products. In addition to participating in the more than 150 research studies, Dr. Heuser has authored more than 400 articles, textbooks and medical manuscripts.

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.

 

   

Richard R. Heuser, MD
Richard R. Heuser, MD

Q: You’ve been involved in interventional cardiology since the early days of balloons and stents. Now, as part of your general cardiology course, you are conducting a day-long session about the transradial wrist approach.
Dr. Heuser: Right – the first two days, it's a general cardiology course; on the third day, it's an all-day radial course. So, people can go to all three days of the course, or they can just do the radial course. We have some of the top interventional people, but also people who are leaders in anti-arrhythmic therapy, leaders in heart failure therapy -- we've got probably the world's top heart failure doctor, William Abraham, there. In the radial course, we have Ian Gilchrist, Tift Mann, who are household names in radial circles. I think it's going to be a lot of fun, so I'd say that the interventional cardiologists, the general cardiologists, the cardiologist that maybe just does diagnostic tests, diagnostic heart caths, all would benefit, as well as nurses and primary care physicians who want a sort of a lay of the land of what's going on in cardiology.

St. Luke's Hospital, Phoenix, Arizona
St. Luke's Hospital, Phoenix, Arizona
    Q: What was your motivation to add the transradial component?
Dr. Heuser: The transradial approach is so relevant to patients, as well as to cardiologists and interventional cardiologists, in terms of being a better way to treat, to do something that we do millions of around the world, and that's heart catheterizations. When I first started doing heart caths in my training in the seventies, I did a lot of Sones procedures, but that pretty much has fallen down, because of the incision and so forth. I started doing transradial procedures around 93 or 94, but the equipment was not great. Now that the equipment has really gotten a lot better -- the last four or five years-- and the data is pretty convincing, from not just RIVAL but other studies, we have switched over to radial access completely in the last year and a half. And we're pretty evangelistic about it: we really want to train physicians, so that not just our patients but other patients have the advantage of this lower-risk procedure.

Q: You started early on utilizing the Sones technique, which is a semi-surgical incision or “cut-down” that uses the brachial artery in the elbow. This is certainly more complicated and requires more skill than the femoral technique. Why didn’t you just go femoral?
Dr. Heuser: Between 1990 and 1994 or so, this was at a time where we were just putting together the criteria in terms of utility of coronary stents, and we used much more aggressive anti-coagulation than we do now. We were using pretty primitive treatment regimens, including heparin and Coumadin. We didn't use Plavix, we used Persantin and we used Dextran, all of these drugs which we just don't use anymore, but we still had an incidence of about 6% of subacute stent thrombosis, ridiculously high. So we actually started bringing patients in fully anticoagulated and doing the procedures with the Sones technique. And we could send the patients home the same day. It was okay, but it’s obviously a lot easier to do this percutaneously, radially.

So, the reason I got started doing radial procedures is that I also see a lot of patients with peripheral vascular disease, and at the same time in the early nineties, I was seeing a lot of patients with occlusion of their aorta. What I would do many times, rather than going in from the groin where I couldn't get access, or doing a Sones where, if I cut down, there was nothing I could do after the angiogram, I felt the best way to infuse thrombolytics at the time was to do it using the radial artery in the wrist. So we were using some 4F catheters that were clearly not meant to be used radially, but they worked okay in order to get access, and at the same time, we shot some coronary angiograms from there. But the catheters at that time were just “Not Ready for Prime Time”, so to speak.

Q: You mentioned that in the last four or five years radial equipment has gotten better. In what ways?
Dr. Heuser: I think that it's not so much the French size as it is the way they're tapered, and there are a number of companies that have really sort of gotten it, sort of taking up the gauntlet to try to improve the tapering of the catheters and equipment, not just the profile. You can have a very low profile catheter, but if it's too stiff, you're not going to be able to get around the subclavian easily, and you possibly could traumatize the subclavian, which for a procedure that should be a lot safer than femoral, you don't want. So we've really been really happy, and it's rare that we have to switch from the radial to the femoral, certainly less than 1%.

Q: Although the transradial approach has been gaining in popularity in the past few years, there are still cardiologists out there who still don't want to even think about it or hear about it. What would you have to say to the many interventionalists who are femoralists only, and don't even want to consider the radial approach at this point?
Dr. Heuser: It's funny -- I train fellows here, and it's simpler with young doctors, and not for the same reasons you would think. It's all about doing an arterial line or an arterial blood-gas and, if you're close to being an intern or resident, you do those a lot on patients and, if you remember what you do to get access -- I mean 90% of it is access, and then with the equipment, it's really pretty simple. If you're comfortable with the access, getting into the artery, and then placing the sheath, the movements in the shafts are very similar to the Judkins technique and, as a lot of people say, the trick is, it’s 90% psychological -- you get in with the arm extended and then once you get access and you get down to the descending aorta, then you put that arm right to the side, then all of a sudden, just think that you're going Judkins.

Q: That's what a lot of people have said: it's really not that different once you've gained access. And also in some cases you're able to use fewer catheters, because you can go from right to left with the same one.
Dr. Heuser: Burt, you're exactly right. The catheters that we use, tend to be universal catheters, the Jacky catheters, the Sarah catheters made by Terumo. We can easily go in the right coronary, easily go to the left coronary, and then even do the ventriculogram with one catheter, and if you compare that to Judkins, where other portions of the groin technique may go faster, this part's a lot faster with radial. So time-wise, it's easily the same amount of time or even less with a skilled radialist.

Q: The uptake of radial in this country has been much slower than in places like India and Japan and Europe, especially France. Why is that and what can be done to improve that?
Dr. Heuser: I think the reason that hasn't happened here so much is that we've got a lot more interventionalists that they do in their countries, and so each interventionalist does less numbers than say, in Europe or in Japan or in India, and I think that's the nature of the beast. On the other hand, it's more competitive here, and so you've gotta have a better product, and you have to have a safer product, and a product that patients are happier with. And I can tell you, there are many things we say in interventional cardiology to patients, we’ll say, "Well this'll be easy, it's under local anesthesia, you'll go home a couple hours later," and then there's the radial procedure, which is pretty much as we say it, and it really is. The patients will come out and you'll see them at the end of the procedure or a couple days later, and they really remark, "Boy, that was a lot easier…that's the only way to do it."

Q: Speaking of the patients, you've had a lot of experiences with patients who have had both femoral and radial, and that's been their experience. But why should someone who has been doing nothing but femorals and, to their knowledge, doing a very good job…why should they learn the radial technique?
Dr. Heuser: Well, you'll reduce your likelihood of vascular complications by four times, and if you look at the most comprehensive head to head trial, the RIVAL trial, you'll see that you will not give up anything in terms of safety and efficacy. You will give up the fact that you will have more blood transfusions and more vascular complications going femorally and, if you look at the sites that were high volume radials, they actually had an improvement in hard outcomes -- that's MI, and morbidity, and mortality. So I think that if I could be so bold as to say, you're doing your patients a disservice if you don't at least consider radial an option in patients... even to the point that they request it... because the reality is, they are going to be requesting it.

Q: In this age of cost cutting and containment, trying to reduce the giant health care expenditures that we have in this county, where does radial fit in?
Dr. Heuser: Well, the fact that you don't need such extensive monitoring afterwards, in terms of the vascular complications, because the vascular complications are done by the time you get out of the lab. You put a TR band or any other kind of compression device on and it's very easily taken care of with a nurse -- a single nurse can take care of a number of patients, and in the diagnostic study, a patient can go home an hour or two after the procedure. In an interventional case, they probably can go home three or four hours afterwards. And we're doing that more and more in patients where insurance will allow us to do these patients truly in an outpatient situation.

Q: My understanding is that sometimes insurance can actually penalize you for doing it as an outpatient procedure?
Dr. Heuser: You are correct, there are some hospital-based fees that you don't get by doing it that way, but I think in the long run what you'll gain is basically happy patients, and probably more patients, and in the long run you'll make up for it in volume.

Q: And the other thing is of course, as the insurance criteria change, and Medicare etc. starts aligning the payment system with better outcomes and being able to use less, costs, that may all change as well.
Dr. Heuser: Yeah. Let's separate the diagnostic study from PCI. And when you look at the fact that PCI, particularly PCI from the groin, is going to have a higher incidence of vascular complications, still fairly low, but still, when you have an incidence of bleeding or hematoma or prolonged hospitalization, even if it's just for a few hours, you start doing the math and it adds up fairly quickly, where you can be a lot more cost effective by doing it radially.

But I think that you're right, and I think that we are going to be pushed by the Federal authorities in terms of keeping our costs down, and more importantly, when we hear statements that patients who come in with a complication after another procedure, you're not going to get paid... I mean, I think that's going to basically jump in the face of physicians, they're going to have to figure out, "How can I do this safely and more cost effectively?" And the other thing is that patients are very knowledgeable, they check the internet, they check, they Google you and they check to see if you're somebody that does these procedures radially, and I think that's going to be more important in the future.

Q: Right. And patients can find hospital and physicians who practice the transradial approach by checking Angioplasty.Org’s Transradial Hospital Locator! Thanks for your time and have a great course.
Dr. Heuser: We will. It’s on September 9-11, 2011 in Las Vegas, Nevada.

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