Cleveland Clinic
A new article about transradial angioplasty (the placement of a stent using the radial artery in the wrist) appeared today in the Cleveland Clinic’s Heart & Vascular Health Blog, authored by their “Beating Edge Team.” Titled, “Unclogging Blocked Arteries Via the Wrist: Angioplasty approach may offer clinical benefits for certain patients,” the article’s purpose seems to be to familiarize patients with this new alternative approach to diagnostic angiography and angioplasty, “now being offered” at the Cleveland Clinic.
Unfortunately this short article, while supposedly an “advertisement” for wrist angioplasty, continues to promulgate several widely-held myths about the radial approach.
For example:
“The relative benefits of radial versus femoral angioplasties continue to be hotly debated within the cardiology community, and the vast majority still are performed through the leg artery. Not all interventional cardiologists are trained in radial access angioplasty, and due to the increased technical complexity, the approach is more time-consuming. There also can be challenges associated with the types of catheters—the long, narrow, flexible tubes inserted under the skin and into the artery to perform angioplasty—available to perform the procedure through the smaller-diameter arm artery.”
Quickly point-by-point:
- Radial vs. femoral may be hotly debated in some cardiology communities, but worldwide the radial technique is used far more frequently than in the U.S.; in China, Japan, India, France, The Netherlands, and other countries radial is the default approach, and has been for some time. The article is correct that “the vast majority of procedures are still done through the leg artery” — but that’s mainly in the United States!
- Not all interventional cardiologists are trained in radial access angioplasty — well this is true because until recently it hasn’t been taught! Now SCAI and other organizations are promoting the radial approach and teaching has ramped up considerably. And allow me a plug here for the Transradial Access Center on Angioplasty.Org which has for years been providing information on this technique, including a list of training courses (for physicians) and a list of hospital centers that practice the radial approach (for patients).
- The radial approach is not more time-consuming nor more complex, if you are trained in it and have some experience. Head-to-head clinical trials have proven this point. In fact the STEMI-RADIAL study, referred to but not named in the article, proves that point. Radial was shown to be superior for the treatment of heart attacks — a clinical situation where any delay in opening up a blocked artery might cost the patient his heart muscle or even his life.
- The smaller diameter artery may present challenges to those not trained in the radial technique, but there are very few interventions that cannot be done via the radial approach. Pretty much any stent, or atherectomy device, can be delivered via a standard 6F catheter system.
If you don’t believe me, read this excerpt from a 2008 article in The Journal of Invasive Cardiology, titled “Transradial Catheterization: The Road Less Traveled“:
“…remarkably, particularly in the United States, the transradial approach is grossly underutilized. So why is there such a reluctance to travel this safer, more comfortable, and seemingly cheaper path to the coronary circulation? One likely barrier, albeit inaccurate, is the misconception that the procedure will simply take longer and be less effective.
To the contrary, several studies, including a recent large meta-analysis, have demonstrated that after a short initial learning curve, procedure length and success are comparable to the transfemoral approach. And, virtually all current interventional devices are compatible with a 6 French system through a radial approach. The more perverse explanation for the relative infrequency of transradial procedures, and probably the more difficult to overcome, is an engrained inertia to change.” (italics mine.)
Oh yeah, the co-author of this four-year-old article which refutes most of the inaccuracies in the Cleveland Clinic article? Dr. Stephen G. Ellis, the Cleveland Clinic’s Head of Invasive and Interventional Cardiology, who is in fact quoted several times in their article today. One wonders if he had a chance to review the piece.
Oddly, the Cleveland Clinic article, in an attempt to promote their offering of and expertise in the radial approach, leads off their piece with this:
“During the past several years, interventional cardiologists at Cleveland Clinic’s Miller Family Heart & Vascular Institute also have begun offering another option: Using the radial (arm) artery in the wrist as the entry point for the procedure. Cleveland Clinic’s interventional cardiologists now perform about 15% of angioplasties using the radial approach each year.” (boldfacing theirs)
Well, now in 2012, having overcome the aforementioned “engrained inertia to change,” U.S. cardiologists now do around 10-15% radials a year. So Cleveland Clinic’s batting average is just that: average.
James Blankenship, MD
For leadership in change, one needs to look to those cardiologists who practice “radial first”, where radial is the default approach; they do almost all of their procedures from the wrist.
Just last week I interviewed Dr. James Blankenship, lead author of the new AD Hoc PCI Guidelines from SCAI, and I brought up the issue of a doubled risk of access site complications when one separates the diagnostic catheterization and the PCI into two procedures on different days. He told me:
Yes. If you’re getting access twice then the risk of access site complications is twice as high. One of the studies showed that. I’ve in fact become totally radial myself. I do 95% of my cases from the wrist.
Did I mention that, when doing angioplasty from the wrist, access site complications approach zero? Maybe that’s why it’s called the “radial approach?” Okay, sorry. A Friday pun….
Anyway, the transradial approach to angioplasty and stenting has been around for 20 years! The U.S. is a late-comer to this technique. And it’s just important not to continue spreading inaccuracies and false assumptions about its advantages and successes.
To be fair, however, Dr. Ellis does state at the end of the article that he “…encourages patients to discuss their options with their physician,” something we at Angioplasty.Org whole-heartedly (oops…’nuther pun) endorse. (For more about patient-doctor shared decision-making, check out our new blog, “The Activated Patient.”)
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