Starting a Transradial Access Program in a Teaching Hospital

Disclosure: The authors report no conflicts of interest regarding the content herein. The transradial approach has been used more commonly in Europe than the United States. In some invasive laboratories in Europe, the transradial approach is used in up to 80-90% of patients.(1) Lately, there has been an increasing interest in performing transradial (TR) procedures in the United States. A recent review of registry data found the proportion of radial access to be 1.3%, with a gradual increase to 3% in the final quarter of 2007. At our institution, the University of Nebraska Medical Center (UNMC), the transradial approach was rarely performed until recently, when Dr. Nattapong Sricharoen started a transradial access program approximately one year ago. The program involves not only teaching interventional fellows, but also general cardiology fellows and cath lab staff, on preparing patients. Some advantages to adopting the transradial approach include fewer bleeding and vascular complications, lower costs and increased patient satisfaction.(2) Transradial access reduces the relative odds of major bleeding by over 70%.(3) At our institution, 108 transradial cases were performed over a period of one year. Two patients had a visibly significant hematoma and one required a blood transfusion. One patient had a radial-brachial artery dissection during the catheterization, but spontaneously healed at the conclusion of the procedures, presumably sealed by the guiding catheter. Two patients had severe spasm and one had severe, tortuous vessel anatomy, resulting in abandoning the radial approach. On six patients, we were unable to obtain radial access. Therefore, the overall vascular complication rate at our institution was only 2%, despite our being still on the upslope of the learning curve. We had a >90% success rate for the first year and the majority of procedural failures were due to an inability to obtain radial access. For the hospital administration, the main advantage with radial access is the reduction in cost. In selected (n=3) patients undergoing elective percutaneous coronary intervention (PCI), we elected for same-day discharge. Patient selection was based on the EASY trial (EArly Discharge After Transradial Stenting of CoronaryY Arteries).(4) The authors of the study demonstrated the safety of same-day discharge after uncomplicated PCI if a bolus of abciximab was given during the procedure. With fewer bleeding complications, this technique also obviates the need for any imaging study to rule out retroperitoneal bleeding, as in transfemoral cases. Overall, the radial approach results in significant reduction of cost as compared to the transfemoral access (even without use of closure devices in the transfemoral approach). Patient discharge within 2–3 hours after a diagnostic procedure is feasible, as compared to 6–8 hours with the transfemoral approach. The radial technique has resulted in less utilization of resources. At our institution, we use regular 21-gauge venous cannulas to obtain radial access and a J-tip Rosen wire (Infiniti Medical, Inc., Malibu, CA) to advance the catheter. Routinely, a 6 French (Fr) hydrophilic sheath (Terumo Medical Corp., Somerset, NJ) is chosen unless the patient is already scheduled for open-heart surgery prior to having a cardiac catheterization. If the patient is scheduled for open-heart surgery, then a 5 Fr sheath is usually used, and the patient will not undergo PCI if found to have obstructive atherosclerotic coronary artery disease. When we started the program, we initially used standard Judkins catheters for diagnostic cases and EBU or JR guide catheters for PCIs. However, as the program matured, we started using a single-catheter technique (Terumo Jacky or Tiger catheters). Immediately after obtaining access, a loading dose of heparin and various amounts (5-20 cc) of a “transradial cocktail” (2.5-5 mg verapamil, 500 micrograms of nitroglycerine and 5 ml of lidocaine, 1% diluted with normal saline) is routinely given. Post-procedural hemostasis is obtained with the TR Band (Terumo). In case of inadequate hemostasis, a blood pressure cuff is inflated on the ipsilateral site and inflated above patient’s systolic blood pressure until bleeding stops, and the TR band is re-applied. Patients undergoing a diagnostic coronary angiogram with uneventful post-procedural course are usually discharged 2–3 hours post-procedure. Patients who underwent PCI via the transradial approach usually stay overnight. However, as mentioned above, selected patients were sent home safely post-PCI. Pre-procedure, the staff attending, along with his fellows, discusses the transradial approach with the patient. Patients were always made aware that the institution had just started this technique and therefore, it may not be successful. The discussion includes the advantages of the approach, including early ambulation and a lower bleeding risk. About 70-80% of patients preferred the transradial approach as their first option for coronary angiogram after discussion. Our staff attending had limited hands-on training when he started using the transradial approach. He increased his knowledge through web-based learning videos. After his successful experience, he started teaching the transradial approach to the fellows. The general cardiology fellow attempts radial access first. If he is unsuccessful, then the interventional fellow attempts, and finally, the attending will attempt. The majority of our patients undergoing the transradial approach were male (65%) with equal procedural success rates in both genders. At present, a total of 104 cases have been performed via the transradial approach, with a 90% success rate, as mentioned above. Out of 108 cases, 71 were diagnostic-only and 37 turned into coronary interventions. We also successfully completed 6 non-ST-elevation myocardial infarctions (NSTEMIs) by transradial access. Currently, STEMIs and peripheral interventions are excluded via the transradial approach. With increasing experience, we plan to expand our patient selection to include higher-risk patients and higher proportions of females, known to be more prone to spasm. All the cardiology fellows and ancillary staff are motivated to learn this new approach. With growing experience and confidence, general cardiology and interventional fellows prefer the transradial approach as the initial approach. Initial reservations by ancillary staff about the longer procedural times were alleviated by increasing proficiency. Procedure times soon equalized between transradial and femoral cases. Staff welcomes the ease of managing the access site, which previously included holding groin pressure for extended period of time to obtain hemostasis. Thus far, transradial access has been a unique and rewarding experience for everyone involved — medical personnel as well as patients. The authors can be contacted via Dr. Syed Ahmed, at syedahmed@unmc.edu. References 1. Popma J. I. The transradial approach. Cath Lab Digest 2009; 17(3): 1, 14, 17. 2. Rao SV, Ou F, Wang TY, et al. Trends in the Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention: A Report From the National Cardiovascular Data Registry. J Am Coll Cardiol Intv 2008;1:379-386. 3. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures: systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349–356. 4. Bagur R, Bertrand OF, Rodés-Cabau J, et al. Long-term efficacy of abciximab bolus-only compared to abciximab bolus and infusion after transradial coronary stenting. Catheter Cardiovasc Interv 2009 Dec 1;74(7):1010-1016. 5. Tremmel JA. Launching a successful transradial program. J Invas Cardiol 2009;21 (Suppl A):5A-10A.

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