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.
That’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.”
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
♥ 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