{"id":34505,"date":"2013-02-07T08:00:30","date_gmt":"2013-02-07T13:00:30","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=34505"},"modified":"2013-02-06T15:50:52","modified_gmt":"2013-02-06T20:50:52","slug":"arms-and-the-interventionalist","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2013\/02\/07\/arms-and-the-interventionalist\/","title":{"rendered":"Arms and the Interventionalist"},"content":{"rendered":"

According to an ESC consensus document <\/a>published\u00a0last week, radial artery access should be the \u201cdefault\u201d choice for PCI. CardioExchange\u2019s John Ryan interviewed cardiologists and interventional cardiologists at different stages of their careers to find out how they view radial artery catheterization, and if the views differ among interventional fellows, faculty, and those in leadership roles.<\/em><\/p>\n

Dr. Ryan:<\/strong> Do you agree with the ESC statement that radial artery access should be the first choice for PCI? Why or why not?<\/p>\n

Megan Coylewright, MD, MPH (interventional fellow, Mayo Clinic):<\/strong> I do agree that radial PCI should be a part of every interventionalist\u2019s toolkit, and I agree with the need to maintain proficiency with appropriate annual volume. I\u00a0believe the statement stops short of declaring that it \u201cshould be\u201d the first choice, but rather that it is \u201cfeasible.\u201d This reflects the ongoing controversy\u00a0surrounding the issue at many institutions, particularly as smaller sheaths and less use of GP IIb\/IIIa inhibitors are becoming the norm for PCI; some feel this diminishes the difference in bleeding between the two approaches.<\/p>\n

Michael Tempelhof, MD (interventional fellow, Northwestern University):<\/strong> Transradial access has been shown to be beneficial on many levels. For patients, the transradial approach is well tolerated and associated with earlier ambulation times and reduced length of hospital stay. Physicians and patients alike benefit from significant reductions in bleeding risk and cardiac death. Healthcare systems benefit from reductions in cost associated with complications and prolonged hospitalization. Finally, as recently reported in the RIFLE-STEACS trial<\/a>, the patients with the highest complication rates associated with PCI have been demonstrated to derive the greatest benefit from the transradial approach.<\/p>\n

For these reasons, I do concur with the ESC statement advocating for the transradial approach for coronary angiography and intervention. A caveat is that the transradial approach is a learned skill requiring strict adherence to a regimented, progressive training plan, as outlined in the ESC document.<\/p>\n

Micah Eimer, MD (cardiologist, Glenview, IL):<\/strong> The data are pretty convincing on the lower rate of complications, and my clinicial experience confirms that. Patients who have undergone both radial and femoral approaches consistently and strongly prefer the radial approach for several reasons, including less discomfort at the site, not having to lie flat on their backs for hours, lack of bruising, and quicker recovery. As a clinician, I am happy to see fewer complications (hematomas, psuedoaneurysms, emboli) and appreciate the ability to send patients to cath without stopping warfarin.<\/p>\n

Therefore, I do agree with the concept, but I am always cautious about substituting guidelines for clinical judgement.<\/p>\n

L. David Hillis, MD, (Chair, Department of Internal Medicine) and Richard Lange, MD (Professor, University of Texas Southwestern Medical School):<\/strong> Although we think interventionalists should be proficient in both femoral and radial techniques, we\u2019re not persuaded that \u201cone access fits all.\u201d Although radial access is associated with fewer vascular complications (primarily hematoma and pseudoaneurysm), its use does not convincingly reduce the occurrence of MACE. Compared with the femoral approach, the radial approach requires a higher level of training and proficiency (which may not be universally attainable). Furthermore, even in centers with extensive experience in its use, radial access is associated with a 7\u201310% rate of crossover to femoral access, increased operator radiation exposure, and radial artery occlusion.<\/p>\n

Dr. Ryan:<\/strong> Do you feel comfortable using the radial approach?<\/p>\n

Dr. Coylewright:<\/strong> Yes, we use it frequently at Mayo Clinic. Speaking with interventional fellows across the country, I anticipate that the use of the radial approach will rise steeply in the next 10 years\u00a0as a result of\u00a0the excellent training we are receiving from our institutions\u2019 experienced radial operators.<\/p>\n

Dr. Tempelhof:<\/strong> Proficiency in the transradial approach for PCI and catheterization of complex coronary anatomy is limited by the nascence and underutilization of the approach in the U.S. Compared with the femoral approach, there is a paucity of advanced equipment and live mentorship programs, which are required to quickly develop an interventionalist into a facile transradial operator. I am comfortable with the transradial approach for diagnostic angiography and type A PCI. However, I recognize that additional experience is required to become competent for complex PCI or cannulation of complex coronary anatomy.<\/p>\n

Drs. Hillis and Lange:<\/strong> Not really. As old dogs (admittedly late in learning new tricks), we\u2019re a part of \u201cGen-S\u201d (\u201cS\u201d for Sones<\/a>). Since we\u2019re very comfortable with femoral and brachial approaches, using a non-femoral approach is not a problem. However, with these approaches, we don\u2019t have to confront radial loops, spasm, and occlusion, and we are not restricted from using large guiding catheters that can be helpful in approaching complex lesions (i.e., chronic total occlusions and bifurcation or calcified lesions). In Texas, where everything is bigger and better, we don\u2019t feel a need to abandon the femoral approach.<\/p>\n

Dr. Ryan:<\/strong> What percent of your current cases are radial, and what percent do you expect to be radial in 3 years?<\/p>\n

Dr. Coylewright:<\/strong> For an interventional fellow, the percent of radial cases depends a bit on the attending with whom we are working; there is a lot of variability among the staff. It is not yet a default approach in our lab. My cases are currently approximately one-third to one-half radial. My future practice will depend in part on my patient population; I see the need for complex left main PCI, rotablation for heavily calcified vessels, and CTO procedures potentially rising as our population ages. Sheath size limits the\u00a0performance of these interventions\u00a0via the radial artery, particularly\u00a0in smaller patients.<\/p>\n

Dr. Tempelhof:<\/strong> I currently complete 24% of all my coronary cases via the transradial approach. Patients\u2019 expectations and demonstrated outcomes benefit will require that I complete 50\u201370% of cases via the transradial approach in 3 years.<\/p>\n

Dr. Eimer:<\/strong> Our interventionalist is probably at 90% radial, and I expect that to stay the same, as its use is limited primarily by unsuitable anatomy.<\/p>\n

Drs. Hillis and Lange:<\/strong> At our hospital, approximately 10\u201315% are performed via the radial approach. In 3 years, that will likely double.<\/p>\n","protected":false},"excerpt":{"rendered":"

According to an ESC consensus document published\u00a0last week, radial artery access should be the \u201cdefault\u201d choice for PCI. CardioExchange\u2019s John Ryan interviewed cardiologists and interventional cardiologists at different stages of their careers to find out how they view radial artery catheterization, and if the views differ among interventional fellows, faculty, and those in leadership roles. […]<\/p>\n","protected":false},"author":133,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[9],"tags":[943,326,595,301,783],"class_list":["post-34505","post","type-post","status-publish","format-standard","hentry","category-interventional-cardiology","tag-diagnostic-coronary-angiography","tag-esc","tag-guidelines","tag-pci","tag-radial-access"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/34505","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/133"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=34505"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/34505\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=34505"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=34505"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=34505"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}