Doc chat: in the cath lab with a “radial evangelist”

19 Jan

by Carolyn Thomas    @HeartSisters

Like most heart patients who get their blocked coronary arteries opened up (or revascularized) at Victoria’s Royal Jubilee Hospital, my stent was implanted by inserting a slim catheter into an artery in my wrist and threading it up, up, up into my heart, a procedure known in the cath labs of the world as a Transradial Intervention (TRI).

But if I had been in an American hospital, my cardiologist would have more than likely threaded that catheter through the larger femoral artery in my upper thigh instead of my wrist, despite growing evidence suggesting significantly safer results, less bleeding, fewer complications, superior outcomes, and resounding patient preference for the radial approach.(1) In fact, while cardiologists across Canada, Europe and Asia are moving towards using radial as a default access, American cardiologists lag behind. 

I just don’t get it. Canadian coronary arteries simply cannot be that much different from those of American heart patients.

In 2008, when I went to Mayo Clinic in Rochester, Minnesota for the WomenHeart Science & Leadership Symposium For Women With Heart Disease, I was the first Canadian ever invited to attend this prestigious training. Not one of the dozens of heart patients from across America that I met there had had angioplasty using the same transradial approach I had experienced.  And most had never even heard of the option

Dr. Jordan SafirsteinThat’s why I love hearing about American interventional cardiologists who do embrace the radial cath. One such doc is self-described “radial evangelist” and “proud New Jerseyan” Dr. Jordan Safirstein of Morristown. Unlike most American interventional cardiologists, he estimates that he uses transradial access in 90% of his cath lab procedures. He generously agreed to this interview:

CT: A bit about your own experience in the cath lab, please: did you go from performing the more commonly used femoral approach, or were you originally trained to do transradial interventions  (TRI)?

JS:   “I was lucky to train where I did under the tutelage of Drs. John Coppola, Tak Kwan and Cezar Staniloae at the late great St.Vincent’s Medical Center in New York City (since closed) – all champions and pioneers of the radial approach in the U.S.

“Dr. Coppola, in particular, was very impactful in my training as he was my Chief, and he sits on the Transradial Working Group of the Society of Cardiac Angiography and Intervention (SCAI). His clinical judgement and wonderful rapport with his patients helped convince me that TRI was a viable and actually preferable approach to cardiac cath.

“I believe when you have a great role model, it helps make you a believer in what you are doing – particularly when most of your colleagues are doing it in a different way.

“Thus, I came out of fellowship with the intention of going radial first and never looked back. I was lucky too, to have wonderful and accommodating staff at my places of work who adapted quickly and also bought into the benefits.”

CT:   What kind of training is available for U.S. cardiologists to learn radial access? And how challenging do you think it is it for cardiologists who are experienced in femoral access to make the change to radial?

JS:   “Since I completed fellowship training five years ago, the number of courses and training opportunities have increased exponentially. We run a wonderful course called the Mid-Atlantic Radial Symposium (MARS) for the past two years, and hope to continue for years to come. We primarily teach docs and cath lab staff, and show challenging cases and issues. Companies that make radial-specific devices have begun to offer proctorships and teaching recently. And independent supporters of the radial approach like Burt Cohen of the website angioplasty.org have publicized locations and info on radial training.

“The challenge of the radial approach is there, but it’s not insurmountable by any means. Education and familiarity is the key, as with anything.”

CT:   How many radial caths would you estimate you’ve done so far?  What’s your groin-to-wrist ratio in general?  

JS:  “I would estimate that since fellowship, I have done around 1,500 radial caths. My ratio is about 90% radial

CT: Are there some patients for whom you’d hesitate to attempt radial as the default approach?

JS:  “Patients with prior CABG (Coronary Artery Bypass Graft surgery) and hemodialysis patients are the most common reason for using the groin (although I have started to use the left radial artery for my CABG patients.  The limiting factor with those patients is accessing the left internal mammary vessel from the right side, so now we just use the left).”

CT:   And what about your female patients? Any issues around deciding on TRI for women?

JS:  “There is evidence that this approach would be beneficial because women have higher rates of groin complications associated with cardiac cath from the femoral approach. A recent study called SAFE PCI, presented at the Transcatheter Cardiovascular Therapeutics conference by my friend and colleague Dr. Sunil Rao at Duke University attempted to address this issue.”

CT:   How much does the whole cath lab team impact a cardiologist’s decision to embrace radial access?

JS:  “It is CRUCIAL that the cath lab staff also believe in the benefits of the radial approach as they are critical to the success of a case in many ways.

“Patients frequently spend more time talking with the staff on the day of the procedure than the physician, and if the staff has bought into the radial approach they will translate that confidence to the patient. Furthermore, an educated and happy staff is the doctor’s greatest asset when things get difficult.

“This is why part of the MARS course is dedicated to staff and the training of nurses and cath lab techs. Staff education plays an even larger role when the operator is in the beginning stages of doing radial. Often, the cath lab assistants have seen and done more radial cases than the operator and can be an invaluable resource technically and morally!”

CT:   We already know that patients prefer radial access because of demonstrated lower rates of complication, infection, bleeding and mobility issues. As I’ve often said, I could virtually leap off the table and tapdance out of the cath lab after each of my two radial procedures.  But are there also advantages from a physician’s perspective?

JS:  “Happy patient, happy doctor. Less work for cath lab staff in terms of groin management – happy staff, happy doctor. Increased referrals, maybe? Less worry over issues like access site complications, etc.”

CT:  Despite their documented advantages, radial caths have not been embraced by American cardiologists compared to those in many other countries. Last June, a study published in Circulation(2) reported that the proportion of radial procedures in the U.S. has increased from just 1.2% in 2007 to 16.1% in 2013 – a significant improvement but still well behind many other countries. Can you help us understand this difference between cardiologists in the U.S. and everywhere else?

JS: “It is difficult to say why U.S. docs have been slower to adopt. It may have to do with the fact that most Program Directors for interventional cardiology are older and slow to adopt or change to the radial approach, which presents new challenges and takes more time. Therefore, those coming out of training are less likely to learn it once they are in practice.

“As more and more interventionalists convert, the young doctors coming out will be more likely to utilize the radial approach as well. I think we are starting to see that as we have gone from ~1% in 2008 to ~15% in 2013.”

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You can follow Dr. Safirstein on Twitter  – @CardiacConsult

(1) Mamas A et al. Influence of access site selection on PCI-related adverse events in patients with STEMI: meta-analysis of randomised controlled trials Heart 2012;98:4 303-311. 6 December 2011. DOI:10.1136/heartjnl-2011-300558
(2) Feldman DN, Swaminathan RV, Kaltenbach LA, et al. Adoption of radial access and comparison of outcomes to femoral access in percutaneous coronary intervention. Circulation 2013: DOI: 10.1161/circulationaha.112.000536

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♥ Patients: wondering if your hospital offers Transradial Interventions? Check here for a list (thank you, Burt Cohen!)

♥  Patients and physicians: share your own experience with radial caths

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16 Responses to “Doc chat: in the cath lab with a “radial evangelist””

  1. Valerie Bales January 20, 2014 at 7:46 am #

    Most of my caths (17 to date) have been through the groin. I finally had a doctor who said his preferred way was radial. Since they took and had to throw away my right radial artery – my left was his choice. After once – he said he would never do me that way again. My arteries are so small – he couldn’t even get my pulse in the left wrist anymore. So, it is good, just not right for everyone.

    Like

    • Carolyn Thomas January 20, 2014 at 12:37 pm #

      Hello Valerie – every patient presents with a unique set of circumstances that determine how suitable any procedure will or will not be.

      Like

  2. Vetia January 19, 2014 at 1:39 pm #

    I think that this is a good subject to cover but not always is the radial cath the best right choice for the patient. Having had more then one and both being in the groin area but they were done that way for a reason. The thing about everyone changing to the radial method my not be in the best interest of the patient.

    I am very small and they couldn’t do the radial cath when I had my heart attack because all the blood vessels had collapsed below the elbow. I had the choice of which to take the next time around. They tested the radial and it wasn’t quite large enough for the smallest port and my cardiologist said he would give it a try if I wanted. I told him to stick to the groin where he knew it would work. I checked into the hospital at 6:30 am, I took both my plavix and aspirin and was on my way home with a band-aid and no problem. What I fear is when things are made the common practice they forget about those of us who fall under the wire. I think six to six and a half hours is the same time you spend in the hospital for the radial. All of this in my book boils down to what is good for the patient. And at my hospital more then half of there caths are done through by the radial method. And yes I am in the USA so you can’t make that claim. It’ just like with all countries if you live in smaller populations of people you may not find the doctors who can do the work and if they can they choose not to live and work in those areas.

    Nice topic but it would be like saying that your health care system in Canada doesn’t work but I know that that is Wrong!!

    Like

    • Carolyn Thomas January 20, 2014 at 12:35 pm #

      Hi Vetia – not every procedure is perfect for every patient, as Dr. Safirstein points out.

      Like

  3. Mirjami January 19, 2014 at 9:49 am #

    One of my 22 heart catheters was done radial. The first one 7 years after my triple bypass. All the others were femoral. I know a friend on whom the cardiologist tried 1 1/2 hours to do the catheter radial and finally gave up and did it femoral. My friend got 4 stents and lied over 4 hours in catheter labor. He was not a heart patient before. It should be only a routine check up.

    Like

    • Carolyn Thomas January 19, 2014 at 11:52 am #

      Mirjami, you may be my most experienced reader when it comes to visits to the cath lab over the years! I’m wondering if your friend’s 1 1/2 hour unsuccessful radial experience was a reflection on the skill/experience of the interventionalist.

      Like

    • Pauline Lambert Reynolds January 19, 2014 at 5:56 pm #

      What is “catheter labor”? Thank you.

      Like

  4. Barbara Bronson Gray January 19, 2014 at 8:14 am #

    This is a very important issue. We’ve got to encourage cardiologists to get the training and the necessary comfort level to adopt radial caths. The feedback from patients continues to be excellent.

    Thank you for yet another great post Carolyn!

    Like

    • Carolyn Thomas January 19, 2014 at 11:56 am #

      Thanks for bringing up that important point, Barbara. If other cardiologists around the world were not already adopting radial caths in significant numbers because they’re better for the patient, I might be somehow better able to buy American reluctance to embrace this option.

      Like

  5. Sunny January 19, 2014 at 7:52 am #

    I wonder if any EP docs use the TRI technique for ablations? It seems that would be preferable to the groin area for all the same reasons!

    Like

  6. Sandy January 19, 2014 at 7:17 am #

    After 16 heart caths in the groin, my leg is shot.

    My regular cardiologist was out of town and the doctor who did my last one left me with a numb leg from the groin to my knee and a large lump in the site. When I saw my regular cardiologist, whom I love, I asked him if I ever needed another one if I could have it in the arm and he said, “You sure can”. He never said, we could switch to the other leg which sort of surprised me. He said, “We do the transradial quite often”.

    I was surprised it wasn’t offered to me in the past. Perhaps they are starting to do more here in Ohio, USA.

    Like

  7. Anne Stohrer January 19, 2014 at 4:34 am #

    My cath at the Mayo was transradial at my own request: very straightforward, no complications except for a quite bruised forearm. At the Mayo they have a special wrist band that applies direct pressure on the transradial site: innovation!

    Like

    • Carolyn Thomas January 19, 2014 at 4:45 am #

      Hello Anne – we have the same wrist band here in Victoria, a type of inflatable cuff that adjusts to apply just enough pressure to prevent bleeding (unlike the weights and staff time required to press on an open femoral artery in the leg).

      Like

      • Pauline Lambert Reynolds January 19, 2014 at 7:01 am #

        Four trips to the cath lab in 2005-2006 were groin access. What a pleasant surprise this year when I had stents placed using the wrist approach! Went home with a bandaid. Like night and day.

        Like

        • Barbara Keddy January 19, 2014 at 12:53 pm #

          Had a groin stent one year ago today and it bled! This is my heart-iversary. Apparently (I was too groggy to remember) while having the HA they went in both groins but only had success in one. I had the biggest, brightest black bikini (well- a bikini would have been smaller, I guess) possible when I left the hospital 5 days later, but not one health professional told me how to care for it. The nurses said I took the prize for the worst one they had seen. It was actually quite beautiful (this said in hindsight).

          It was so uncomfortable walking though. A neighbor, a physiotherapist, came over and told me to push a heating pad tightly into the groin while at the same time moving both knees back and forth. It worked and by the next day I could walk comfortably, but the deep black abdomen lasted for months.

          Like

          • Fiona January 20, 2014 at 8:59 pm #

            It seems they use both procedures here in Australia. I’ve had two angio’s, the first a radial which left me with a horribly painful black and blue forearm and a small hematoma which the nursing staff and doctors couldn’t understand, and the second through the groin, which I had no problems with. My second angiogram finally diagnosed the cause of my heart attack, a post partum SCAD (Spontaneous Coronary Artery Dissection) and given the danger of further dissections for SCAD patients during an angiogram, I definitely want to be aware of the safest way for them to be performed in case I ever need another.

            Like

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