Transradial Access: A Look at Education

Dr. Coppola has been teaching the transradial technique for five years. How long have you been performing transradial procedures? I began performing transradial procedures in November 2003. Why learn and how did it come about? In New York State, we track all of our complications in the cath lab. I have been cathing since 1981 and cath lab director since 1993. Over the years, I’ve had occasion to see a lot of femoral complications. St. Vincent’s is a busy lab, so every 12-18 months we would have at least one death we could attribute to a femoral complication. I had one personal experience involving a horrendous, long case. A nun presented in our cath lab in cardiogenic shock. I opened up her artery and was able to save her from cardiogenic shock. Then she developed a complication in her groin, which led to surgery, and further complication. She eventually ended up going into renal failure and needing dialysis. Then came hyperalimentation, followed by becoming septic and developing a fungemia. About eight weeks after a successful angioplasty for cardiogenic shock, she died. Given this experience, and being aware of some of the procedural complications experienced by other operators in my lab, I was eager to find ways to mitigate complications. When I was offered an opportunity to go to India and learn the transradial procedure, I decided to pursue this as a possible way to reduce complications. I was lucky enough to travel to Ahmedabad, India, and work with Dr. Tejas Patel. He has performed probably the largest number of radial procedures in the world. At the time I was there in 2003, Dr. Patel had done about 18-20,000 procedures; he’s probably closer to 30,000 now. I went with a colleague of mine, Dr. Tak Kwan, and we spent an intense week with Dr. Patel. We probably scrubbed on about 110-120 cases in that week and became very friendly with Dr. Patel. He was our encouragement to begin a transradial program at St. Vincent’s. What were some of the challenges you faced in starting a transradial program? At the time, Dr. Kwan and I were the only ones who wanted to do this procedure in our lab. Both of us had done a lot of transfemoral work, so the nurses knew we could do a diagnostic in a few minutes transfemorally. The transradial approach required a change to our room setup and the procedure, and it took a bit longer in the beginning. This seemed to fluster and annoy the team. We realized we had to win them over to the procedure. In short time, they not only saw us get better at the transradial procedure, but they also saw how the patients ambulated quickly. Everything ended up going so well that it led the nurses to become advocates of the radial procedure, to the point where they are now our greatest supporters. Sometimes it can get you into trouble. One of my nurses was moonlighting on the CICU, and had a female patient who was really afraid of being cathed. So my nurse told the patient, oh, don’t worry, they’ll do it through your wrist, it’s not going to hurt, it’s going to be easy. It turned out that the patient’s cardiologist didn’t do radial cases and he was livid. He thought I was soliciting cases through my cath lab nurse. I ended up having to scrub on the case, get radial access, and do the case for him. Tell us about the learning curve. There is a definite learning curve to this procedure and a logical approach to becoming proficient and gaining support from your team. In my training courses, or in general conversation with others, I always tell people that the quickest and best way to gain critical support from your staff is to start off by doing very easy cases. I believe we all benefit by starting with a 45- or 50-year-old man, with a nice size arm, a big, bounding, radial pulse and nice anatomy. The nurses quickly see the benefits: the introducer is removed, a radial compression device or bandage is in place, and the patient is up walking to the bathroom on his own, and happy with the quick and easy mobilization post-procedure. Then, once you have done 25 to 50 cases, they realize that you know what you’re doing and are more inclined to cut you some slack. It’s like anything else. When your team sees that you are doing a good job, they support you. Even if you have a difficult case, they say, hey, this guy knows what he’s doing. He just had one difficult case, but it’s a great technique. Conversely, if your earliest attempt is an 87-year-old woman who’s been hypertensive for the last 60 years, it’s tripling your time to do the case. The staff is not going to be on your side. The focus on the learning curve as a roadblock is interesting, because there are so many other new procedures that come out where there is also a learning curve. I’ll tell you what I believe is behind the reluctance to learn this technique. We spend our entire fellowship learning how to do femoral cases. By the time you come out of fellowship, you are competent at doing a femoral angiogram. After doing 400-500 femoral cases, you can say, I’ve got this mastered. With the transradial technique, you have to master the basics all over again. How do I get into the artery? Once I get into the artery, how do I maneuver the catheters? These challenges are all ego alienating, as psychiatrists would say. People think to themselves, I’m an expert in cardiology. I’ve been doing this procedure for 15 years. I can hit a femoral artery in my sleep. Now I’m taking 10 minutes to cannulate the radial artery?! That’s one of the things with the learning curve. It’s not like learning how to use a new device; it’s not like saying okay, I’ve never used this FoxHollow device to do an SFA and now the sales representative is here telling me what to do. Transradial access is basic. Boy, I can’t even get access to an artery. Do I look like a jerk! That’s why there is such a big deal about the learning curve. What is the state of transradial education in the U.S.? As Dr. Sunil Rao has pointed out, approximately 1% of all PCI cases reported from the ACC-NCDR in the United States are done radially. One reason is that many fellowships do not teach the radial technique. After we learned and introduced transradial access to our lab in 2003, Dr. Kwan and I started to teach radial angioplasty to our interventional fellows. Then we began teaching the procedure to our first, second and third-year fellows. Our fellows are exposed to both radial and femoral access, so when they leave, they’ve done a couple hundred transradial cases and are confident as radial operators. Some have been training other physicians in the radial technique. It’s a reverse pyramid. You start with two people, Dr. Kwan and myself, and we train three interventional fellows and 60 diagnostic fellows. Then those fellows go out and train others. This has been the case with Sanjay Patel in the Houston area. Zaheed Tai, in Winter Haven, Florida, is training physicians and is also one of my fellows. Jack Chen and Sal Mannino in Atlanta are doing a lot of radial work and they were also my fellows. Our hope is that we have created a groundswell which will result in more transradially trained physicians in the United States. We have been training physicians in our lab, supported by Terumo. Physicians spend time in our lab with us, see how we are doing things and how we negotiate some of the problems. It’s funny — when we don’t have guests in the lab, the cases go smoothly, but when everyone is here, we somehow end up having the most bizarre anatomy, with radial loops and anomalous subclavians. Recently, I had a guest with me for 12 cases. Every case had something unusual, either a radial loop or an abnormal takeoff of an artery, and it was frustrating for me. Meanwhile, my guest was standing there saying, “Oh this is great, I love to see you work like this, because it teaches me what to do when I get into these situations.” How is St. Vincent’s radial training course structured? The course was initially conceived as a two-day course with about eight people. Dr. Kwan and I ended up thinking it was too much of a zoo scene and not good learning. We’ve since restructured the training as no more than three people, but ideally conducted as one-on-one training. We want really experienced angiographers. They’ll scrub in with us. We’ll show them how we stick the radial artery and how we manipulate the catheter, and let them get the feel of it while they are here. How many cases do you try to do when you have trainees? It varies. My last training involved 10 cases. Our last formal course was held in October. Between four radial operators at St. Vincent’s, Dr. Kwan, Dr. Michael Liou and Dr. Kurian, we had about 18 cases. Once they leave and go back to their facilities, what support do you offer? I give them all my cell number and email contact information. I tell them to contact me if there is any question or if there is anything you want to know about the equipment we use and what to do in a particular situation. So far we’ve gotten some very good feedback from course attendees who have gone back and started to do radials. What’s your sense of the level of interest in the procedure? It is frustratingly high. Actually, this should be a good problem. It means that more physicians are recognizing the need for and benefits of transradial access. Since we started in 2004, we’ve probably had 100 trainees here as guests. In the past year alone, it’s probably been about 50 people. Interest has truly climbed as a result of all the data coming out that documents bleeding complications and their relationship to mortality, and about the ease of radial access. As third-party payers push for same-day angioplasty, same-day discharge, you’re going to see even more people interested. As a training program director, I do think that radial access is something we should be formally teaching our fellows. I recently worked with a program director from Loyola in Chicago. He came here and spent a day with us. Then, he went back to Loyola and started doing radials. Now he’s teaching his fellows how to do radials. We’ve been talking to Terumo about setting up a website where you can view and read about tips and tricks for radial access. I would be filmed getting access into a radial artery. Maybe then we would go into another lab and look at another operator getting his radial access and see if it’s different. Now if someone wants to start radial work, you can go onto a website and look at a little two-minute video. Okay, I like Operator 1’s technique better than Operator 2. We’ll show tricks with cannulation and catheters, and how we get around loops. How can the cath lab team support physicians who just beginning? The radial artery itself has a very strong sympathetic innervation. When people get nervous, their sympathetic system turns on and they get vasoconstriction. When we first started to perform radial procedures, we noticed our patients seemed to have a fair amount of spasm. We had to really sedate people and knock them out to do the procedure. Interestingly, as we got more competent with the procedure, I think the patient picked up on our confidence levels. Initially, they may have picked up on our tentative approach to the procedure: “Am I going to do this procedure…do you think I’m going to get into the artery…I hope I get into the artery. If I get into the artery, am I going to be able to get into the coronary arteries? Oh man, I’m not going to be able to do this!” I think the anxiety we and our staff felt may have shown in the early days and resulted in our patients being more anxious and having more spasm. Now our nurses are at the point where they think transradial access is the greatest procedure in the world. They tell patients that they will love the procedure. Once the cath is over, the patient should be up and moving around rather than having to lie still. They also tell the patient how good I am! Just the fact that the nursing staff is so supportive makes a major difference. Occasionally, there are cases that you can’t do as a radial case. You walk into the room and the nurses have the case set up as a radial. You have that awkward moment when you say, “No, the lady is a dialysis patient, she has a shunt in her arm, I can’t do this as a radial case…aw, shoot.” The staff is actually pushing us to do more and more. It even got to the point where we now do bypass cases through the wrist. We used to do bypass cases just as groin cases, and one day, the nurses had set up the patient as a wrist case. “What are you doing? It’s a bypass!” “Oh, we were hoping you could use the wrist.” We started using the left wrist so we could do the left internal mammary and now do our bypass cases that way. All because of our nurses pushing us. After the procedure, everything comes out in the room. There is hemostasis in the room. The patient goes upstairs, the patient can sit up. If the patient has to urinate, he can stand up and use the urinal. If it’s a woman, she can go in and use the bathroom, she doesn’t have to use a bedpan. You don’t have to worry about the groin bleeding. It’s one thing that’s out of your mindset. Do many patients come in knowing about radial access? It’s still something we need to explain to people. Once they’ve had it done that way, however, they say, “Can’t you do it through my wrist again?” We’ve gone on to ask some of these patients which way they thought was better. “The wrist was a lot better, doc, I really liked that, I like the idea of being up and being able to walk around.” Have you ever had a transradial patient and a femoral patient cross paths post-procedure? Yes. I can remember one guy who was up and walking around the room, while another patient actually had a hematoma and was on bed rest with sandbags on. He was less than happy! Do you do peripheral work via radial access? We actually have a paper coming out in Catheterization and Cardiovascular Interventions (CCI) where we report on 42 iliac stents done through the radial artery. We do a lot of iliac stenting, some common femoral work and some totally obstructed aortas through the radial artery. I do all my renal stenting through the radial artery. Do you think fellows have a different motivation for learning the transradial procedure than more experienced operators? I think fellows are enthusiastic about everything. They see this as more technically advanced or challenging, so they want to learn it. I also think that fellows are pragmatic and they see it as a marketing tool. Some of my fellows who have gone out in the last couple of years have really marketed themselves with the radial technique and have built a practice based on it. Dr. Sanjay Patel, in Houston, has been interviewed on television and in the newspaper, all because he was the first one doing radial procedures there. Cardiologists who are out in practice see it maybe as a marketing technique, maybe as a way of keeping up with insurance companies because they demand same-day angioplasty. I’m also hoping that they are actually looking at some of the data saying radial access is safer. If you bleed and get transfused, that’s bad. We also know that if you use the radial approach, bleeding complications are cut by more than 50%. If you really want to take care of patients and do the best by the patient, you should say, I’d better learn how to do this technique. I think that message is starting to get across to the American cardiologist. Cardiologists in Asia and Europe have known this for a long time. It’s interesting that you went to India for your training. Part of the problem is this intrinsic narcissism in the United States. The American ego is just so stupid. I was talking to a friend of mine who is an Indian cardiologist in India. In the U.S., if you do 10 mitral valve repairs a year, you’re a pretty big operator, right? So I asked him, “How many have you done?” He said, “I don’t know…maybe five or six thousand?” In India, rheumatic heart disease is very common. This cardiologist worked in a government hospital and was doing 10 valvuloplasties a day for the first 10 years of his practice. We don’t realize the sheer number of people in China and India. The fact is that these people are good operators despite working with often terrible equipment. It’s time we accept cardiology is global. We should be willing to accept ideas from all over the world if they are good for patient care. It sounds like you have a passion for not only your work, but for teaching. I’ve been doing this with the fellows for a long time. It’s probably the part of my job that I enjoy the most, teaching the house staff and the fellows. Dr. Coppola can be contacted at jcoppola@svcmcny.org

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