Transradial Access as Part of Growth at the University of Texas Medical Branch

Can you tell us about your facility and cath lab?

The University of Texas Medical Branch (UTMB) opened in 1891 as the first public medical school and hospital in the nation. We are located in Galveston, Texas, about 50 miles southeast of Houston. UTMB has a long history of advancing health science education, research, and patient care. We are a level I trauma center along with multiple satellite clinics throughout Texas. At UTMB Cardiac Catheterization Lab/Electrophysiology (EP) Lab, we run three cath suites and one EP suite. The team consists of cardiologists, interventional cardiologists, cardiology fellows, interventional fellows, registered nurses, radiologic technologists, and patient service specialists. Our patient population includes inpatients, outpatients, and correctional managed care.

What attracted you to the radial approach?

Luisa Anderson, RN, MSN, CVRN-BC, Director, Cardiology Services: When Dr. Gilani approached me with the idea of radial access in 2010, I thought it was a good idea because of increased patient satisfaction. The patient does not have to lie down for 4-6 hours after the procedure. Patients are able to sit up and ambulate early. 

Malinda Roque, RN, MSN, CVRN-BC, Cath/EP Nurse Manager: At the time of initiation seven years ago, I was a staff nurse in the cath lab. A concern for the nurses was the prep time for radial approach compared to the groin. With repetition and time, we were able to prepare the radial just as fast as the groin. The nurses realized it was better for the patients and brought lower possibilities of bleeding complications. 

Syed Gilani, MD: I was attracted to the radial approach because it offered reduced access site bleeding and easy post procedure access site management. Increased patient comfort was also another factor. We adopted radial access as a default for coronary cases in late 2010. At that time, we were heavy users of glycoprotein (GP) IIb/IIIa inhibitors, especially in acute coronary syndrome patients, and as expected, we had cases of femoral access site complications, despite taking measures to reduce such complications. This would lead to prolonged hospitalization and patient dissatisfaction. In our cath lab post procedure, our trainees (cardiology fellows) pull the sheaths. Since moving to mostly transradial procedures, we have rarely had any significant bleeding complications, despite continuing to use GP IIb/IIIa inhibitors for appropriate patients.

Umamahesh Rangasetty, MD: I am an interventional cardiologist and an associate program director for the interventional cardiology fellowship. Patient comfort, early mobility, and less bleeding complications really attracted me to adopt this approach very early in my career. 

How long has radial been a part of your lab and how did you get started? 

Malinda: We began to do radial cases seven years ago with Dr. Gilani as our faculty. He provided education to the nurses and fellows. We started with diagnostic cases and a few months later, we included percutaneous coronary intervention (PCI) cases. After we developed our workflow and the team felt comfortable, we included ST-elevation myocardial infarction (STEMI) patients. 

Dr. Gilani: We started with the help of our cath lab staff, invasive faculty, and trainees (cardiology and interventional fellows). In our cath lab, invasive cardiologists perform most of the diagnostic procedures and if an intervention is necessary, then interventional faculty is called. We started to gradually but quickly shift from femoral to radial access for coronary procedures in mid to late 2010. Considering the benefits of radial access for our patients, especially reduced access-related complications, we all agreed that this was the right thing to do. Initially, a few of our invasive and interventional faculty started radial access and over a few months, as we became more comfortable, all invasive faculty started considering radial as the first choice for their cases. Our trainees were very eager and happy to learn this technique. We have been training our interventional fellows in transradial primary PCI since early 2011. As a team, we trained our cath lab staff by educating them about the benefits of radial access. With the help of our cath lab staff, we quickly learned to prepare the radial access site using the basic tools (brachial drape, arm board) in our cath lab. Our staff was very eager and adopted the best and quickest way of preparing for radial access for our procedures. We have learned to use the standard guiding catheters (Extra BackUp,  [EBU], Judkins left (JL), Judkins right [JR], and Amplatz, also used in femoral access) to perform transradial interventions. For diagnostic catheters, we mostly use the Jacky and Tiger catheters. One of our cath lab radiologic technologists (Ajay Bhatia, RT) came up with an idea to reduce radiation exposure to the operators. He created a lead cover for the arm board that is placed on the right side of the patient’s abdomen (between the patient’s right arm and abdomen).

Wissam Khalife, MD: I am one of the invasive/heart failure cardiologists at UTMB. I was among the first cardiologists who started radial access at UTMB and in the Houston area in early 2010. I have performed more than 1000 diagnostic caths using this approach. My patients were very satisfied with the experience due to less risk for complications, less pain, and mostly the ability to ambulate and discharge home much sooner than with the femoral approach. I did help to train all our cardiology fellows and was able to present our radial experience in many national and international conferences as poster and oral presentations. Currently, radial is my standard approach. I use femoral access only if radial anatomy precludes using radial. UTMB is the among the first academic centers in Texas to use the radial approach and all our fellows who graduated after 2010 are currently using this approach as standard access. I really think that the radial approach did make a coronary angiogram much easier, safer, and simpler for our patients. 

What procedures are being done with radial access? What restrictions/patient criteria are utilized?

Dr. Gilani: We have been performing radial primary PCIs (for STEMI) since early 2011. We regularly perform trans- radial chronic total occlusion (CTO) PCIs, high-risk transradial PCI with support (using an intra-aortic balloon pump [IABP], Impella placed via femoral access), and some peripheral interventions, especially renal artery and iliac artery stenting procedures using radial access.   

Dr. Fuijse: I was one of the late adopters of radial approach. I am thankful to Drs. Gilani and Rangasetty for working together with the other faculty and cath lab staff, and getting the program up and running. Seventy percent of my PCIs are now done transradially. Because I prefer 7 French (Fr) for PCIs, I use 6-7 Fr Slender sheaths a great deal. I still do my CTOs transfemorally, however. I believe that overall patient experience has improved quite a bit with transradial approach. 

Tell us about the learning experience when you first introduced radial access.

Malinda:  Each faculty has their preference on access, but a majority of our physicians use radial access. The fellows are trained under the supervision of the faculty. At first, the staff was concerned because it was time-consuming to prep the patient and also, we had to adjust the arm quite a bit during the procedure, which caused the procedure to take longer. However, as we developed the workflow with the physicians’ and staff’s input, it became second nature. Also, the staff was anxious when transradial was first introduced. They felt that it would be more painful for the patient and would increase complications because it was a small vessel. After extensive inservices and developing a protocol, their concerns were alleviated. 

Dr. Gilani: We started by performing diagnostic heart caths and interventions in elective and low-risk acute coronary syndrome patients in mid 2010. Our cath lab is high volume and very soon, within a few months (late 2010), we started performing higher risk coronary interventions. 

What steps did you take to streamline your protocol to accommodate radial? 

Malinda: Our EMR orders were modified. Management worked closely with Dr. Gilani on development of the radial compression band removal and guidelines. Data were gathered from other facilities that were using radial approach. 

Tell us about the post-procedure to discharge process for radial patients. 

Malinda: Post PCI, our compression band removal is based on an activated clotting time (ACT) result of 160 or less. The radial sheaths are removed immediately after the procedure and a compression band is placed. Air is inserted in the band with a syringe and released per protocol. 

What have you seen with your complication rate?

Dr. Gilani: We have noticed a significant reduction in access site bleeding rates. Our patients are spending less time in the hospital and getting discharged home without any access site complication delays. We have published our data comparing transradial vs transfemoral primary PCI in STEMI patients, showing a significant reduction in access site complications and reduced hospital length of stay.1 

Has use of radial access had an impact on procedure volume?

Malinda: Overall, our volume has been increasing. I can account for an increase in patient satisfaction and less occurrences of hematoma in our recovery room. 

Dr. Gilani: Our cath lab procedure volume is growing every year. There is no way to be sure how much of this could be due to impact of radial access. However, our patients frequently tell us how they liked having their procedure done through the radial artery, and that they tell their friends and relatives about it. It is very satisfying to hear from the patient how much they appreciated having radial access and not having to lie flat on bed rest post procedure.  

How did you get the word out that radial access was available at your facility? 

Malinda: The word spread from our nurses, fellows, and faculty. The nurses on the floor provide education to the patients on cardiac catheterization, which helps patients understand their options. Many patients come in stating, “I want my procedure from the arm.” The cardiology clinic has also been a key component in educating the patients. 

Dr. Gilani: We conduct a monthly regional conference in collaboration with our colleagues from regional institutions. We regularly present our transradial cases and challenges to the regional colleagues. This has helped increase adoption of radial procedures in regional hospitals. 

How have patients responded?

Malinda: The response has been great. Patients enjoy being able to sit up immediately after the procedure, as many of our patients have chronic back pain. The patients can also eat sooner via the radial approach. Being able to use the bathroom versus a bedpan has been a part of some of the positive feedback. 

Dr. Gilani: Patients are very happy and satisfied with the care they receive. Frequently, our patients ask for radial access for the procedure and are excited to hear that we have been using this as our default access site for several years. 

Dr. Rangasetty: They really love it, particularly the ones who had several femoral procedures in the past. I have many patients come to me and tell how their friends were surprised to hear that we went through the wrist instead of groin to do the stent procedures. Lately, I have been getting referrals from our own patients just because I did radial procedures and I am very happy with that.

Is there equipment that has become a workhorse for you in radial procedures? 

Dr. Gilani: We use a brachial drape and a radial board for preparation of the access site. We use Glidesheaths with Angiocaths and at times, a micropuncture access kit for radial access. We use a radial band for post-procedure hemostasis. For diagnostic coronary procedures, we use multipurpose catheters from the right radial access. For interventional procedures, we use the standard guiding catheters (EBU, JL, JR, Amplatz) that are also used in the femoral access to perform transradial interventions. We also use 125 cm multipurpose and 125 cm pigtail catheters for diagnostic peripheral angiography using radial access.

Dr. Rangasetty: I tend to use ultrasound guidance more often to get radial access as it increases the chances of getting the access at first attempt, particularly during STEMI interventions. I used to perform sheathless guiding catheter interventions for complex coronary interventions such as CTOs, bifurcations, etc., but moved on from it due to the availability of Slender sheaths.

Has your lab implemented same-day discharge?

Malinda: All of our diagnostic cases are discharged the same day. Diagnostic cases usually discharge within two hours. The fellow must assess the radial site before discharge. All patients that undergo fractional flow reserve (FFR) testing are discharged the same day. The recovery room nurses provide a follow-up phone call to ensure there are no complications. In the future, the plan is to implement same-day radial PCI. 

Dr. Gilani: In our cath lab we frequently perform FFR and imaging (intravascular ultrasound [IVUS], optical coherence tomography [OCT]) for invasive evaluation of coronary artery disease. We have a protocol to discharge the select patients who undergo FFR/OCT/IVUS the same day after transradial access. We have been doing this for the past five years or more. We have not yet started same-day PCI discharge. 

Do you have any advice for labs that may be interested in developing a radial program from scratch or in ramping up an existing program?

Ensure proper education is provided to the nurses and fellows for post-op care. Develop a protocol for the care of radial access patients. 

What do you think is the most important message to someone still struggling to adopt radial access? 

Be open to change and inquire at other facilities. For our department, there was a misconception that it would take longer for our STEMI cases. With practice and preparation, there was no difference in our access time. 

What are your plans for the future?

Malinda:  Future plans include a reduction of the recovery periods for diagnostic radial cases and implementation of same-day radial PCI discharge. 

Dr. Gilani: We do plan to start same-day PCI discharge soon. Our lab is also getting ready to start a transcatheter aortic valve replacement (TAVR) program and CardioMEMS in a few months.

Reference

1. Bheemarasetti MK, Shawar S, Chithri S, Khalife WI, Rangasetty UM, Fujise K, Gilani SA. Influence of access, anticoagulant, and bleeding definition on outcomes of primary percutaneous coronary intervention: early experience of an US academic center. Int J Angiol. 2015 Mar; 24(1): 11-18. doi: 10.1055/s-0034-1394158

The authors can be contacted via Malinda Roque, RN, at malroque@utmb.edu.