Radial Artery May be Safest Route for Threading Catheter to Heart

Cooks believe the way to a person’s heart is through the stomach, but interventional cardiologists may soon be paying close attention to the wrist. New research shows that radial artery access significantly reduces bleeding complications during angioplasty and stenting, cutting by nearly 60 percent the risk of bleeding complications following percutaneous coronary intervention (PCI), while maintaining a high procedural success rate. However, the study also shows that interventional cardiologists use the radial approach in only about one in a hundred PCI procedures. “Over the years we have paid a lot of attention to improving the safety of PCI by altering drug regimens, but we can also improve safety simply by using the radial approach rather than the femoral approach,” said Sunil V. Rao, MD, an assistant professor of medicine at Duke University Medical Center, Durham, NC, and director of the cardiac catheterization laboratories at the Durham Veterans Affairs Medical Center. “Radial PCI is clearly safer than femoral PCI, and procedural success is equally good.” The study’s findings are especially notable because they are drawn from the National Cardiovascular Data Registry (NCDR). This enormous database, operated by the American College of Cardiology (ACC) in partnership with the Society for Cardiovascular Angiography and Interventions (SCAI), contains information on more than 1,500,000 PCI procedures performed at more than 850 hospitals. It provides a rare, “real-world” glimpse of how the radial technique is used in everyday practice throughout the nation. “This is the largest report ever published on the safety and efficacy of the radial approach,” said Ralph Brindis, MD, MPH, a co-author of the new study, ACC vice president, and former chair and chief medical officer of the NCDR. “Not only is the large size of the study important, the data registry also gives us the opportunity to see how this procedure is performed by a whole gamut of interventional cardiologists with a range of procedural volumes and skill levels.” For the study, Dr. Rao and his colleagues reviewed all records from the NCDR CathPCI Registry between January 2004 and March 2007, selecting only those representing first-time PCIs done with radial or femoral arterial access in non-emergency cases. The final study group represented 593,094 patients. Of these, 7,804 patients (1.32 percent) were treated using radial artery access. Investigators found that PCI success was equally high with the radial and femoral approaches (95.53 percent and 94.68 percent, respectively). Bleeding complications were far less common among patients treated with the radial approach, 0.79 percent, as compared to 1.83 percent with the femoral approach. When a variety of characteristics that might influence the likelihood of bleeding were taken into account, the risk was significantly lower among patients treated with radial PCI (odds ratio: 0.42). In addition, bleeding complications were less common with radial PCI in patients traditionally at higher risk for bleeding, including women, the elderly, and patients experiencing acute coronary syndromes. However, the data showed interventional cardiologists were less likely to use the radial approach in such patients. Dr. Rao said that the general reluctance to use radial PCI may stem from a perception that it is more difficult and time-consuming than femoral PCI. In fact, smaller, more flexible catheters have overcome many early problems with radial PCI. Data from the NCDR study showed that procedure times averaged only a few minutes longer with radial PCI, and that the volume of contrast dye was no different when compared to femoral PCI. The real problem is that many interventional cardiologists are not trained in the radial technique, Dr. Rao said. Enthusiasm may be growing, however. Investigators noted a surge in radial PCI to about 3.5 percent of procedures in the first quarter of 2007. That could be good news for patients, and not just because of a reduction in bleeding risk. With the femoral approach, patients must lie flat in bed for several hours after PCI while heavy pressure is applied to the puncture site in the groin. “With the radial approach, the catheter is removed immediately after the case, and the patient can sit up, walk around, or get something to eat. They’re much more comfortable,” Dr. Rao said. In the meantime, the NCDR CathPCI Registry will enable researchers to keep tabs on the latest trends in radial PCI. In fact, what began in the late 1990s as a tool for improving quality of care has become an invaluable resource for clinical research and evaluation of interventional devices, Dr. Brindis said. “The study by Dr. Rao and colleagues is a perfect example of what a national treasure the NCDR CathPCI Registry is in allowing clinicians to understand the real-world application of PCI.” Source: Journal of the American College of Cardiology (JACC): Cardiovascular Interventions, August 2008.

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