An Editor’s perspective piece about the transradial (wrist) approach to angioplasty and stents appears in the current issue of “Circulation: Cardiovascular Interventions.”
Penned by Associate Editor J. Dawn Abbott, MD, the article, titled “Diffusion of Innovations and Adoption of Transradial Intervention,” explores why it has taken so long (and continues to) for the transradial approach to be adopted widely in the U.S., given that the evidence from clinical trials has been clear, and that the economic and patient comfort benefits are evident. Dr. Abbott concludes:
“New innovations must be assessed not only for the outcomes examined in clinical trials, but also for physician training requirements and system readiness. With this approach a more formal dissemination process can be developed that will minimize risk and prevent the market from driving the uptake of procedures prematurely. Professional societies and physicians in leadership positions need to assume a dominant role in this process so that regulatory and payer groups do not take the responsibility from us.”
Dr. Abbott’s observations come at an important time in the adoption of this technique. More than 20 years ago, Dr. Ferdinand Kiemeneij’s group in Amsterdam began exploring ways to use the radial artery in the wrist for interventional procedures, such as delivering balloons and stents. Adoption of transradial intervention (TRI), however, has been slow, especially in the United States. As of 2007, only 1.2% of all U.S. coronary interventions were done via the wrist; virtually all procedures were still being done using the femoral artery in the groin/leg, a technique perfected by Dr. Melvin Judkins in the 1960’s.
This is changing, however, as Angioplasty.Org recently reported: the transradial approach is now being used more than 15% of the time in the U.S. (I keep specifying “the United States,” because in the rest of the world, TRI has been used far more frequently.)
Part of this sudden increase in adoption is a function of training, and Dr. Abbott points this out. It is very difficult to assess the benefit of a new procedure when there is a dearth of experienced practitioners.
But, like many innovations, including the introduction of coronary angioplasty itself, which I was honored to play a part in, it starts with specific people in specific centers. In the case of TRI, cardiologists like Dr. John Coppola experienced cases where the femoral approach led to serious complications, even death, in patients who had had successful angioplasties. (You can read more about this in my interview with him.) These cases led him to look beyond the status quo and brought him to India, where he learned the wrist approach from Dr. Tejas Patel. Along with other pioneers in TRI, such as Dr. Tift Mann, Tak Kwan, Jack Hall and more, these cardiologists started performing TRI and teaching others. A second and third generation of “radialists” took hold in the U.S. and by the end of 2013, Angioplasty.Org predicts that one out of five interventions in this country will be done through the wrist.
Training is critical to the success of the procedure. A good way to scuttle innovation is to have it implemented sub-optimally. So if anyone is interested in pursuing the transradial approach, we strongly urge you to attend one or more of the many courses available.
An immediate way to start would be to sign up for the NYC TRAC course starting on Friday!