The Successful Transradial Program at Crittenton Hospital Medical Center

Samer Kazziha, MD: My interest in transradial access was always in the back of my mind. It began more than 25 years ago, when I was involved in performing a couple of radial procedures during my training, just as a trial. At the time, radial access was challenging, due to equipment and catheter restrictions. Yet, in recent years, I saw how this method of access was becoming more and more prevalent, and knew that if we adopted the transradial approach, it would enhance patient safety² and satisfaction while becoming more cost efficient.³ 

At Crittenton, what benefits did you gain by adopting the transradial approach?

Jackie: Our vascular complications decreased significantly, reaching close to zero. We experienced no significant bleeding and minimal overall blood transfusion rates, if any.⁴ In addition, our costs decreased due to lower length of stay for both diagnostic and interventional heart catheterizations. Over a few years we had a significant pharmacy savings by utilizing heparin rather than bivalirudin. However, most important was increased patient satisfaction scores. Patients liked the shorter hospital stay and less physical restriction post radial access procedure.

Dr. Kazziha: The advantages of transradial access include fewer complications, improved patient satisfaction, cost effectiveness¹, and less time required by nursing staff to care for patients³. Our vascular complications, including hematomas, pseudoaneurysms, and the need for transfusion, have decreased to nearly null⁴ since most of our physicians are now performing transradial access procedures. Transradial patients usually do not require overnight stays, do not have prolonged nursing care, and the patients feel at ease³ as they are cared for by the same nursing staff pre and post procedure. Patients are happy to go home sooner than later. Administrators on the other hand, are pleased with the cost effectiveness of transradial procedures. This is really a win-win situation for patients, physicians, and the hospital.^1,5

Advantages of Transradial Approach to PCI:

• Reduced bleeding risk;
• Reduced length of stay and costs;
• Early ambulation;
• Improved patient comfort;
• Avoid discontinuation of oral anticoagulant therapy;
• Same-day discharge.³

What was your pathway to transradial implementation?

Jackie: Dr. Kazziha led the team of nurses, cardiovascular technologists, and mid-level providers in implementing our program in 2010.  We initially started with a select patient type, but quickly expanded to all patients. Once cath lab staff was comfortable with the new process, hospital nurse educators began house-wide nursing staff education with the assistance of cath lab nurses, technologists, and mid-level providers. After initial training, the mid-level providers were responsible for ongoing education of nursing staff, placing appropriate discharge orders, and monitoring post procedure for possible complications, including calling patients 24 hours post procedure. Once cath lab and floor nurses were comfortable with the new process, Dr. Kazziha began training other cardiologists in the transradial process. Early in 2011, marketing of our radial program by the hospital began and continues to the present day, providing information on the benefits of transradial access during cardiac catheterization.

Medtronic now has the Transradial Arc Curriculum (Figure 1) that offers comprehensive education and training for both physicians and staff, which we have been part of. 

Dr. Kazziha: Initially our program started with me performing transradial access for a few months before I gradually began training other physicians. Within 3 to 4 months of starting our transradial program, we had performed over 100 elective percutaneous coronary intervention (PCI) procedures. We then transitioned the program to performing primary PCI transradially and increasingly challenging procedures. 

What is your inclusion/exclusion criteria for transradial access?

Dr. Kazziha: The standard has always been using the Allen’s test (Figure 2) and unless it is abnormal, then the patient is a candidate to undergo transradial access.¹ An Allen’s test is just one of the criteria. We also avoid patients who might have issues with vasculitis, which might affect the radial or ulnar arteries, although this is also a rarity. We avoid doing transradial access in patients who have had end-stage renal disease and are being considered for an arteriovenous (AV) fistula for dialysis in order to preserve the integrity of the vessels. 

CONTRAINDICATIONS FOR USE OF TRANSRADIAL ACCESS:⁵

• Abnormal Allen’s test, oximetry/plethysmography;
• Need for IABP, devices incompatible in ≤7 Fr sheaths like TEC, larger Rotablator (Boston Scientific) burrs, larger stents;
• Upper extremity peripheral vascular disease.

What technique do you prefer to gain radial access and what equipment do you use?

Dr. Kazziha: I use a single-wall puncture technique. I advance the access needle slowly, allowing me to feel the pulse transmitted through the needle. Once you get brisk blood return, you change the angle from 45 degrees to about 30 degrees, and then you advance the wire without difficulty. I use a nitinol wire with a floppy tip. For access, you want to have a floppy wire initially to get into the vessel, to minimize potential spasm or dissection. I don’t use long sheaths. I am comfortable with a standard short sheath. I tend to use sheaths which can accommodate a 5 or 6 Fr guiding catheter if needed, where the outer lumen is like a 5 Fr, but the inner lumen can accommodate a 6 Fr if necessary. 

Having the proper catheters and sheaths has made a big difference in making the procedure seamless. I am very pro small catheters. I use 5 Fr diagnostic and guiding catheters and get very nice filling of the vessels, angiographically. Having a variety of catheter shapes have allowed a single catheter to engage both the left main and right coronary artery (RCA) angiography is an. This is doable in about 80% of the cases and it is also cost and time savings. In order to be efficient, a cardiologist needs to become comfortable with certain catheters, use them regularly, and then, 9 times out of 10, they can engage the vessels of interest without difficulty. 

Can you tell us about post procedure management?

Jackie: Our cardiac catheterization pre and post order sets were updated to include radial access procedure orders. Our mid-levels are responsible for placing orders and following patients pre and post cardiac catheterization. Pre procedure, staff perform bilateral Allen’s test and routine labs are completed. Any abnormal findings are reported to the mid-level and/or physician. Immediately post procedure, the radial arterial sheath is pulled by our cardiovascular technologists. We do not wait for the activated clotting time (ACT) to be less than 170; we pull while the patient is still on the table. A compression device is then placed and hemostasis is confirmed prior to transfer to the post procedure recovery area. 

Once in recovery, the procedure nurse and recovery nurse confirm hemostasis and the amount of compression used. Decompression of the device is followed per manufacture recommendations. After all compression is released, the device will be removed. During recovery phase, the access site is monitored closely for potential bleeding and/or hematoma. Diagnostic catheterizations are discharged in 2 hours post procedure, while interventional procedures are discharged within 6-8 hours. Patients with chronic kidney disease, cardiomyopathies, or other major co-morbidities are placed in extended recovery overnight. Our mid-levels are responsible for monitoring all patients post procedure and notifying the physician of any potential complication. 

What is your pressure reduction protocol? 

Our pressure reduction protocol when using Medtronic’s TRAcelet Compression device, a dial-based system, is detailed in Figure 3.                                                      

Can you tell us about same-day discharge at Crittenton?

Dr. Kazziha: When I presented transradial access as a means to same-day discharge to administration, they were skeptical. It took them awhile until they realized the significance of such procedures, on savings, and the impact on patient satisfaction.¹ I don’t think there is a patient who wants to stay in the hospital longer than they have to. About 80% of our transradial elective PCI procedures actually end up going home within 6-8 hours of the procedure. We call our patients within 24-48 hours to check on them, and they are usually seen for follow-up within a week. Over the last 6 to 7 years of performing transradial procedures and sending patients home within 6 hours of their elective PCI, no patients have come back with any complication of significance to the emergency department or for readmission after early discharge. Our patients have done quite well. Patients who are kept overnight include elderly patients over (80 years old) who cannot have anyone be with them at home, people who live far away, patients with acute renal failure or chronic kidney disease, patients who have severely depressed left ventricular (LV) function, and patients who have signs and symptoms of heart failure.^6-8 

CRITTENTON HOSPITAL MEDICAL CENTER’S PROTOCOL FOR SAME-DAY DISCHARGE:  

(If any one below, will be admitted overnight for observation)

PRE-PROCEDURAL CONSIDERATIONS:

• Age > 80 years
• Residence > 60 min or inadequate social support
• GFR < 60
• LVSF less than 30%
• Patients with signs and symptoms of heart failure

PROCEDURAL CONSIDERATIONS:

• Significant left main disease
• Use of glycoprotein IIb/IIIa inhibitor
• Complex PCI (e.g. CTO, multivessel or bifurcation PCI, atherectomy)
• Complication (e.g. dissection, slow/no-reflow, side branch occlusion

POST PROCEDURAL CONSIDERATIONS:

• Active/recurrent chest pain
• Hemodynamic instability
• Bleeding or vascular complications

Why do you think Crittenton’s transradial program has been so successful? 

Jackie: Definitely teamwork. Our program’s success could not have been achieved by one person alone. It could not have been just Dr. Kazziha wanting to perform radial access. He involved all cardiac cath lab staff so they had ownership in the process and worked towards its success. Everyone in the cath lab embraced this new concept, from the unit secretary to all the physicians, nurses, technologists, and mid-level providers. Once all physicians began performing radial access, our statewide data revealed that we were, in fact, experiencing significantly better outcomes than other hospitals⁹ for vascular complications and rate of blood transfusion. Crittenton Hospital has one of the lowest rates of adjusted PCI morbidity and mortality in the state of Michigan.⁴  

What is next for transradial access and your program?

Dr. Kazziha: We are performing more complex interventions via transradial access. Transradial access is here to stay. Over the next 5 years, you will find more physicians performing mostly transradial procedures. For the bread and butter of coronary angiography and intervention, transradial access is going to be the main procedure performed across the country.

A special thank you to Vicki Smith, ARRT(R)(M)(CV), and Charles Bilinski, CVT, for sharing their vast knowledge in cardiac catheterization procedures and taking the lead in developing staff protocols for our transradial program. Their dedication and commitment to our transradial program has led to a success that far exceeded our expectations when we began the program. 

References

1. Rao SV, Tremmel JA, Gilchrist IC, et al; Society for Cardiovascular Angiography and Intervention’s Transradial Working Group. Best practices for transradial angiography and intervention: a consensus statement from the society for cardiovascular angiography and intervention’s transradial working group. Catheter Cardiovasc Interv. 2014 Feb; 83(2): 228-236.
2. Fischman AM, Swinburne NC, Patel RS. A technical guide describing the use of transradial access technique for endovascular interventions. Tech Vasc Interv Radiol. 2015 Jun;18(2):58-65.
3. Rao SV, Cohen MG, Kandzari DE, et al. The transradial approach to percutaneous coronary intervention: historical perspective, current concepts, and future directions. J Am Coll Cardiol. 2010 May 18; 55(20): 2187-2195.
4. BMC2/Cath PCI data for Ascension Crittenton Hospital. On file.
5. Pinto B, Patil S, Rao A. Transradial vascular interventions – expanding indications and increasing safety. Chapter 12, Medicine Update: 63-67. Available online at https://pdfs.semanticscholar.org/51d2/73d54604d7c315d696d2785ad9d3c48fd5c5.pdf. Accessed September 17, 2018.
6. Brayton KM, Patel VG, Stave C, et al. Same-day discharge after percutaneous coronary intervention: a meta-analysis. J Am Coll Cardiol. 2013 Jul 23; 62(4): 275-285.
7. Dickens C. Creating a same-day discharge PCI program using transradial. Diagnostic and Interventional Cardiology. March 8, 2011. Available online at https://www.dicardiology.com/article/creating-same-day-discharge-pci-program-using-transradial. Accessed September 17, 2018. 
8. Why you should be working toward same-day discharges for PCI. Advisory Board. January 19, 2016. Available online at https://www.advisory.com/technology/crimson-continuum-of-care/members/expert-insights/same-day-discharge-for-pci. Accessed September 17, 2018. 
9. Not evaluated in a head-to-head comparison.

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