Most Popular Angioplasty Web Site
    Radial Center on Angioplasty.Org Radial Center on Angioplasty.Org with support from Medtronic Cardiovascular
Angioplasty.Org Interview Series: Transradial Approach
Email Bookmark and Share

Interview with Sanjay Patel, MD, FACC

Dr. Sanjaykumar Patel, MD, FACC practices diagnostic and interventional procedures at the Sadler Clinic in the Houston, Texas area. He was one of the first interventional cardiologists in the Houston area to use the transradial approach and has performed more than 1,000 transradial catheterizations.

Dr. Patel earned his Bachelor of Medicine & Bachelor of Surgery from Smt. NHL Municipal Medical College, Gujarat University in India. He completed his Internal Medicine at New York Medical College, NY, where he served as Chief Resident in 2003-2004 and then completed a fellowship in Cardiovascular Medicine and Interventional Cardiology at St. Vincent’s Hospital and Medical Center in New York. He is board certified in Interventional Cardiology, Cardiovascular Diseases, Nuclear Cardiology, Echocardiography and Internal Medicine.

Dr. Patel now runs monthly transradial training courses in an effort to promote the use of the wrist approach. A complete listing of educational offerings for the transradial approach, including Dr. Patel's upcoming courses, can be found on the Transradial Training Courses page in Angioplasty.Org's Radial Access Center.



Sanjay Patel, MD, FACC
Sanjay Patel, MD, FACC

Q: How did you become interested in the transradial technique and how did you learn it?
Dr. Sanjay Patel: I finished an interventional cardiology program in June 2008 at St. Vincent’s Medical Center in New York and I witnessed the development of the radial program there which was started back in 2003-2004. We became the training site for the last couple of years and had an international faculty: Dr. Shigeru Saito, Dr. Tejas Patel, Dr. Samir Pancholy and Dr. John Coppola, who is my mentor and the program director at St. Vincent’s. All these great transradialists came over and we had some great exposure in technique, the essentials of transradial intervention and diagnostic angiography.

Plus, I'm from India and the city where I was born, Ahmedabad, is where Dr. Tejas Patel's practice is. So every time I go there I visit him, go to his cath lab and always learn more, always there is something new. So that also helped me to get some exposure outside of the United States. After finishing my fellowship I moved here to Houston and accepted my first practice out of training.

"Angioplasty.Org is awesome; I always refer patients to it. It makes a difference big time. They go and they look and see all the people interviewed and these well-known cardiologists around the world talking about it, and it takes that anxiety away. Ultimately they sense your confidence in the way you tell them, and they will go for it."    

Q: When you came to Houston, were the people who hired you aware that you did transradial?
Dr. Sanjay Patel: When I came here no one was doing any transradial, zero. I was supposed to be working at three hospitals: Memorial Hermann and St. Luke’s Community Medical Center, both in the Woodlands, and Conroe Regional Medical Center in Conroe, Texas. They all had cath labs, very active interventional programs, and were private hospitals -- no teaching programs. I expressed my interest in transradial to the administration, cath lab supervisors and management staff. They were happy to hear that and accommodated all my needs for specialized catheters or introducer sheaths.

The first 10 cases I did were all transradial and really established the program in all three hospitals. The multi-specialty practice I joined had six cardiologists and I was the seventh. None of the six were doing transradial. They sort of had an idea of it, that people had been doing it more and more, but all of them were surprised to know this approach. Even the 35 primary care and 50 internal medicine physicians whom I met during the interview, they were all surprised. For some of them, it was the first time they'd even heard about it.

Q: What about the patients?
Dr. Sanjay Patel: As I started interacting with the patients and I discussed with them the approach, wrist vs. femoral, at first they would have no idea. You would see their mouths drop and they'd be surprised and amazed, "Is this even possible?" They would look at me suspiciously. The first few patients were like, "Doctor, is this experimental?" And I had to refer them to your website, Angioplasty.Org, to show them the literature. Your website is awesome; I always refer patients to it. It makes a difference big time. They go and they look and see all the people interviewed and these well-known cardiologists around the world talking about it, and it takes that anxiety away. Ultimately they sense your confidence in the way you tell them, and they will go for it.

Q: Has using transradial has been an advantage for you in your practice area, to differentiate you from other hospitals and practices. Do you find that patients are coming to you specifically because you do transradial?
Dr. Sanjay Patel: Obviously it was new for everyone, including the cath lab staff, the support nurses, the patients and the family. After we did a few cases, we had a patient story put out in a local newspaper. So that was a great head start. Everyone became more aware. The referring physicians got involved. I made some local presentations at the physician-to-physician level.

I differentiated myself in the community because my doing transradial was a huge advantage for me in attracting the patient referrals -- because all my patients, they loved it!

    1st Radial Procedure at Memorial Hermann Hospital
Dr. Patel, Cath Lab Staff and 1st Radial Patient at Memorial Hermann Hospital

Since coronary artery disease is a chronic disease, often the patient already has had a procedure done through the femoral. Now they come to me, for whatever reason, either their insurance changes or they’ve relocated or they're changing their physician, and now I do them through the wrist and they were my best advocate, my best marketing tool. They went out and said, “Hey, great! This is the same thing I had through the groin, but then I had to lie down for hours.” Surprisingly, all they remembered was how long they had to lie down after the femoral procedure. Some of them had a bleeding complication requiring a blood transfusion, increasing length of stay. But none of them would talk about the heart attack or the angina. All they would mention were the complications.

When we went through the wrist, some of them went to work the same day. Very quick recovery, no lying down, they could immediately come out of the cath room and sit up, eat. Slowly I started getting referrals from cardiologists in the community. It's a very competitive market here.

I actually got several obese patients, weighing 350-450 lb., who had been turned down by cardiologists for catheterization because the groin, the femoral artery, is simply not accessible in those patients. And a couple of them needed bariatric surgery. But in a 350 lb. patient a stress test is always going to be abnormal because of artifacts, or it will be inconclusive and then they would not get clearance for bariatric surgery or Lap-Band® or whatever procedure they needed to have. It's ironic. But I was able to do those patients through transradial and I could say, “You have no problems. You're cleared for whatever surgery you need to have done.”

Q: Do you do all of your cases transradially?
Dr. Sanjay Patel: My first preference is transradial. So far 94% of my work is transradial. I check with an Allen’s test and very rarely, if the right side is abnormal, I go for the left wrist.

Q: Have you had many complications from radial?
Dr. Sanjay Patel: So far I recall there were a couple of cases of local hematoma, which resolved just with observation. So far no hand ischemia, zero complications requiring blood transfusions or increasing length of stay. There were a handful of patients with some residual discomfort and pain for a week or so which resolved eventually. That tends to go away in a week.

Dr. Sanjay Patel in cath lab doing a radial procedure    

Q: You have started a training program yourself and already have held several sessions this year.
Dr. Sanjay Patel: After I started doing these cases there was a lot of interest and a couple of cardiologists would come stand next to me and say maybe you can show me all the tips and tricks. And then the local representative of Terumo, which makes all the Glide Sheaths and catheters, they had their staff or representatives from different areas including Denver, Dallas, come here to spend the day with me.

I always wanted to spread this technology and I said maybe we can come up with a training program where the physician would come, spend a day with me and, if possible, get hands-on training, and take it to their communities and practices.

Q: What do you think is the best way to learn this? Obviously, if you're able to go to India and stand next to Tejas Patel, that's wonderful, but it's not practical for everyone
Dr. Sanjay Patel: The best thing would be obviously, the fellowship training program, incorporate radial in all the interventional cardiology fellowship programs. Plus, for practicing cardiologists, I would say there should be a sort of mini-fellowship, where the training programs that are doing high radial volumes will have a week training program on transradial and that would be very good for already established interventional cardiologists.

Q: What about live demonstration courses?
Dr. Sanjay Patel: Those work -- obviously you can watch and pick up some tricks and tips. But you want to have some hands-on experience, including from the needle stick to passing the wire, to handling the catheters -- because it is a completely different animal, going from the wrist, as opposed to the groin.

What I see is the frustration for someone who wants to learn this; they go out on their own and they're trying to do the procedure radially and, if they don't know how to troubleshoot, they will really get frustrated, the procedure will get longer, the hospital is not going to like it, the cath lab staff is not going to like it, the patient is not going to like it. So there is only so much you can learn by watching it.

I think you should really get involved, spend time with someone who has been doing it. Just spending a day is probably not enough. It could be a good start, but you need to really dedicate yourself and be persistent. You have to be persistent.

    Dr. Sanjay Patel in cath lab doing a radial procedure

Q: When you came to Memorial Hermann and the other hospitals, how did you work with the nursing staff, the technologists, to teach them, because the set up is different, is it not?
Dr. Sanjay Patel: The first and foremost thing I did was have a meeting with them. Then I had a little didactic session -- I showed them with simple explanation how to even prep the patient, because they never even prepped a transradial patient. I had a hand board ordered. I showed them some slides. I made a formal presentation with everything. And then, in the first few cases, I was there as the patient was getting prepared from the beginning, like putting the patient on the table and standing there and doing everything myself, showing them this is what my expectations are, this is how you want to do it.

So I had to go over some of the technical aspects, which are very different than from the groin. It took probably the first 10-15 cases before the whole cath lab staff was comfortable. And after that, they just loved it. Because post-procedure I pull out the sheath myself, I put the TR Band to achieve hemostasis, there is no need to use any closure devices, complications are low, patients are going home much faster and quicker post-PCI, regardless of what anti-coagulation they are on, the sheath is coming out. It facilitated the whole process so much that they just started loving it. “This is great” -- that’s all I hear from them now.

Sanjay Patel, MD, FACC
    Q: What about the hospital administration and the economics of doing transradial as an outpatient procedure? There’s a lot of incentive to cut costs.
Dr. Sanjay Patel: I think the radial approach for both catheterization and PCI should be the gold standard in the coming years. The reasons being, number one, a tremendous amount of cost saving if you look at the complications and the cost to deal with those complications, including blood transfusion, imaging studies, length of stay -- far more than managing coronary artery disease with a procedure. Number two, there's greater and greater emphasis on outpatient PCIs. I believe Medicare is now only paying the hospitals for outpatient PCI, regardless if you keep them in the hospital or not. So, hospitals are already losing money keeping patients overnight. In a couple of cardiology meetings, it came up to do outpatient PCI and I was the first one and the only one to say “yes” – to have my patients same day discharge. And the reason is because of transradial.

I have such a sense of confidence when I finish my procedure through the wrist, I never have to worry about bleeding complications and never have to worry about their ambulation or any groin complications. We actually are going to start a pilot project where we will be sending the patient out the same day after transradial angioplasty. The hospital administration is very supportive because of all this cost saving. And the patients love it. No one wants to spend a day in the hospital unless they have to.

Q: This whole field of the transradial approach is growing.
Dr. Sanjay Patel: And recent studies about mortality, morbidity and PCI outcomes now, we all know by all the studies looking at meta-analyses and everything, that PCI outcome is directly related to the bleeding complications. If you lower bleeding complications, you are hitting the target to improve PCI safety, mortality and morbidity.

Q: Are there times when it's probably best not to do radial, even if the Allen’s test is all right? Are there certain procedures better done femorally?
Dr. Sanjay Patel: If you have distal peripheral arterial disease which is below the iliac, up to iliac, I have done these cases through the wrist. But anything below the iliac involving below the knee, we do not have longer catheters or balloons, so there is a technical limitation.

Carotid intervention is probably challenging, even though I see some case reports from around the world where they are doing carotid through the wrist, but I still see a major challenge in terms of the technical equipment. The equipment is just not ready for that.

The other thing is anything requiring greater than a 7F procedure, which is very rare actually. 90-95% of cases are being done with a 6F intervention. So a minority of the patients who need some complex PCI or large burr rotational atherectomy, bifurcation stenting, those 7F or more would be a limitation because of the size of the radial artery. But other than that, if you feel the pulse and if your Allen is normal, then I think you should just go for radial.

Q: What about equipment?
Dr. Sanjay Patel: Most of the catheters and everything are designed for the groin, but I think you are going to see more and more product lines specifically for radial: Terumo has them, Medtronic has started. My procedural time doing radial diagnostic cath is actually shorter than femoral. The reason being that I use the Jacky Optitorque™ catheter which I use instead of three different catheters: I go in, I enter in the left ventricle and do my left ventriculogram, then I get into left coronary, then right coronary -- just with one catheter with no exchange, one does it all. The fluoro time, as well as the procedural time, is shorter for a diagnostic coronary angiogram with radial than with femoral.

It's also less expensive. The first time somebody is watching and I go in and out and it's done, they're like, “What?” Because they normally see people exchanging catheters three times, over the wire. And the safety is higher using one catheter because every time you exchange the catheter, there is always the potential for embolization. You maybe have a clot which you can dislodge, every time you introduce the system in and out. So it makes an excellent point to complete the procedure with one catheter.

Q: In the U.S. radial is used in less than 5% of cases, as opposed to other countries like India, the Netherlands and France. Why is that and how do you think it could change?
Dr. Sanjay Patel: I think what we need is community awareness. Because once we have community awareness, once the patients and the people who need this procedure come to know about it, they will ask for it. Once they start asking for it, there is going to be a growing desire for getting trained. Certainly we can get help from the societies. People are focusing already: they are talking at TCT, they're talking at SCAI, and they’re talking at American Heart Association, American College of Physicians annual meetings. So, once we have those: societal support, community awareness and more and more training sites, we will see the growth.

This interview was conducted by Burt Cohen of Angioplasty.Org.