SCAI: Transradial program may require time investment, but ‘worth it’.
San Diego — When launching a program to train cardiologists in the radial technique, cardiac cath labs should be prepared to face logistical challenges for a substantial period of time, despite the safety and comfort benefits to the patient, based on a case study presented at the Society for Cardiovascular Angiography and Interventions (SCAI) 33rd annual scientific sessions.
Transradial access (TRA) for cardiac catheterization has been shown to have a markedly lower rate of complications compared to the femoral approach; however, there has been a very low rate of U.S. adoption of TRA. According to the authors, one of the barriers to U.S. adoption is a lack of training of fellows in TRA techniques.
Several studies have documented a steep learning curve for TRA. As a result, the researchers embarked on a TRA outpatient strategy in July 2009.
To evaluate the effect on the cath lab of launching an outpatient, transradial PCI program, Michael Lim, MD, director of the cardiac cath lab and interim cardiology director at St. Louis University Medical Center in Missouri, and his colleagues analyzed data from the first 53 patients in whom a radial artery puncture was used to access the arterial system, comparing them with a matched group who had earlier undergone PCI using femoral access (FA).
St. Louis’ outpatient cath lab has a rotating second or third year fellow and an attending interventionalist performing the procedures. The researchers noted that TRA was not attempted in patients with an abnormal Allen’s test, end-stage renal disease (requiring arteriovenous fistulas), previous CABG and the need for combined right heart catheterization.
Lim and colleagues reported that TRA access was successful in 46 patients (87 percent).
Comparatively, they found that:
- Time to establish access in the TRA group was 7.57 minutes versus 4.17 minutes in the FA group.
- Procedural success was 83 percent in the TRA group versus 96 percent in the FA group.
- Fluoroscopy time was 10.01 minutes in the TRA group and 4.07 minutes the FA group.
There were no vascular complications in either group, according to the authors.
“In our program, we have three interventional cardiologists and eight senior fellows (year two-three) that participate in transradial cardiac catheterization,” they wrote “Compared to our own femoral experience, we show a higher procedural failure rate and fluoroscopy time. Thus in a teaching center, the learning curve for adoption of newer techniques is significantly longer.”
“Our study showed that it’s going to take a lot more than 50 cases before everything goes as smooth as silk,” said Lim. “There’s good reason for doing transradial PCI, and we need to keep that in mind. The commitment has to be there from the beginning.”
He concluded, “It is absolutely worth it. Patients who have undergone catheterization procedures using the wrist are much happier. I truly believe in transradial PCI, but the reward is long term.”
Editorial, Cardiovascular Business, May 5, 2010.