A TCT Symposium For Your TRI Questions

In this month’s TCT special edition, I wanted to draw attention to ongoing efforts to better understand the influences that transradial has had and will continue to have as it relates to the cardiac catheterization and intervention. My interview this month is with Dr. Ajay Kirtane, from New York-Presbyterian/Columbia University Irving Medical Center, and Dr. Amit Amin, from Barnes Jewish Hospital. Both physicians will be part of a panel taking place at TCT (see box) and I have asked them to share their perspective on a few questions that are pertinent not only to their opinions, but as to why attending the symposium could be valuable to your lab or practice.

— Gary Clifton, Vice President, Terumo Business Edge

Why is transradial access an important part of your clinical interventional practice?

Ajay Kirtane, MD: There are really two aspects to this: patient comfort and clinical outcomes. When I first started doing transradial procedures as my default, I immediately noted that there were less phone calls about pseudoaneurysms, hematomas, discoloration, etc. These calls literally just went away. And the clinical outcomes differences related to bleeding complications are especially clear. Additionally, there is something to be said for the ability of patients to get up and move so soon after the procedure. I personally think that explains some of the effects seen in randomized trials relating to mortality.

Amit Amin, MD: Bleeding and vascular complications are quite morbid and matter a lot to patients. I go radial first because not only do these adverse outcomes almost vanish with radial access, but there is rapid recovery and greater patient comfort. I will add that another major reason to go radial first is an economic one. Aligned with the rapid recovery of radial access, care pathways can be optimized such that early and rapid discharge can be achieved which translates into a reduction in resources utilized and hence costs.

Will the recent Society for Cardiovascular Angiography and Interventions (SCAI) consensus paper will have a positive effect on increasing utilization of same-day discharge for percutaneous coronary intervention (PCI) patients?

Dr. Kirtane: Yes, to some extent. These manuscripts are important, but sometimes have limited reach. Spreading the message of same-day discharge is something that really takes a concerted effort.

Dr. Amin: Society guidelines are important and provide the practicing physicians a framework for what they do in their day-to-day practice. The recent SCAI guidelines are a great example of the SCAI society’s initiative to push forward an important aspect of PCI care. I believe that these guidelines will encourage physicians to examine the efficiency of their PCI discharge processes more carefully.

Recognizing that healthcare is struggling with rising costs and lower reimbursements, is greater use of same-day discharge a must-have or a “nice to have”?

Dr. Kirtane: I am personally a convert. We have a same-day discharge program that is not specific to transradial practice, but is certainly helped by transradial PCI. I do think that this is a great way to be more efficient and save on systemic costs, and thus I view it as a “must” going forward. One caveat, though. It is important to come up with ways that the costs of the procedures are not just shifted to the patients, because in some healthcare plans, patients bear a greater co-pay for outpatient vs inpatient stays.

Dr. Amin: For those participating in the voluntary bundles, same-day PCI is a must-have. It improves efficiency and throughput, and frees up valuable resources for hospitals to meet the challenges of bundled payments. And for those not participating in bundles, saving resources is always a plus. As these same-day PCI processes become more mature, hopefully payers recognize the benefits, and some of the variation in co-pays for patients and reimbursement for hospitals that we see today will perhaps go away in the future.  

At this year’s TCT meeting, you will are participating in a sponsored symposium: “An Expert Transradial Q&A Panel: Generating Clinical and Economic Value.” What do you think your peers can learn about the use of transradial as it relates to clinical and economical value?

Dr. Kirtane: Personally, I think that there is too much entrenchment that goes on in the endless femoral vs radial debates. This type of symposium can help to allow bridges to be built and really emphasize that radial is just a way to stay current, learn new skills, and offer a more expansive set of options to patients. The fact that it can save money and improve outcomes is just that much better.

Dr. Amin: I agree with Dr. Kirtane. It is not really about a debate. When we keep the patient at the center, transradial is really about developing a skill set for offering even complex patients a means to achieve excellent clinical outcomes, at a lower cost, and with greater patient comfort. We need to also recognize that there will be a subset of patients who will always require femoral access. Personally, for me, this is not debate; it is about providing patient-centered care.

This symposium is a different format for TCT. It is focusing on fielding questions from the audience vs presentations from panelists. Do you have a sense of the questions your peers are seeking answers to?

Dr. Kirtane: We have done audience participation programs at TCT before and they are always great. My sense is that there will be a range of questions, from “why should I do this” to “what if I’m having challenges” to “how did you start”, and all questions will be well received. There is a lot of practical knowledge out there that colleagues are hungry to access.

Dr. Amin: We did a similar symposium at the SCAI meeting. It was a huge success and well received by the audience. When there is no script and free-ranging audience discussion, it taps into the rich clinical experience of the panelists and brings forth questions that the audience is most interested in. TCT is the place to be for this interesting discussion!