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Transradial Catheterization at the Arkansas Heart Hospital
Can you tell us about your cath lab?
We have cath labs at both the Little Rock Cardiology Clinic (LRCC) and the Arkansas Heart 
Hospital. The LRCC has two diagnostic cath labs and we perform about 3,000 cases per year. The Arkansas Heart Hospital has five coronary catheterization laboratories and two electrophysiology labs. We do about 7,000 cases/year.
When did you begin the transradial program?
We started it two years ago, after I basically became fed up with growing groin complications. After changing closure devices, and trying different ambulation protocols and catheter sizes, I decided that the only way to avoid groin complications was not to stick the groin in the first place. I came in and said, they are doing radial access in Japan and Germany and India, so why can’t we do it? The staff immediately bought in, and we have been going full bore ever since, to the point where over half of our cases within the group are done radially.
Anytime you try something new, especially if it’s a little bit outside what is routine, you always 
wonder if people will be cooperative or resistant. Our staff has been enormously cooperative and intimately involved in the development of protocols, preps, and just in coming up with new ideas. Everybody participated in developing the process. It has been a very enjoyable experience.
How did you approach training?
We all had some experience with radial access from my internal medicine career and having done a smattering of cases during my fellowship, so I felt comfortable starting out. I also had experience doing a number of brachial access cases. I trained myself, using my experience in both femoral and brachial access. Learning to do radial access is a trial and error process, honestly. I started out with a very gradual approach, doing procedures on middle-aged patients who I felt would be very easy radial candidates. We have a few diagnostic laboratories in our clinic building, and that’s where we actually started doing radial access. I did between 30-40 middle-aged men, and then I started expanding indications. After about 50 diagnostic procedures, I brought radial access over to the hospital, and started doing interventions as well.
How did you train your team?
Three of our staff were very interested in learning radial technique. I had them ‘blaze the trail,’ if you will. We taught them how to prep properly, and even taught them even how to do the radial access. A physician, if he wants to, can always do the access, but our techs are now very adept at gaining radial access on their own.
That is certainly unique!
It was exciting was to see how staff embraced their ability to gain the access for us. It led to a great deal of enthusiasm within the staff and honestly, a little competition to be able to say, hey! I can do this as well. Our staff has been doing groin access for years. Most tell me it is easier to stick the radial artery than it is to stick the femoral artery. I did require them to train with me to understand the anatomy. They had to do a number of directly supervised accesses so I could sign them off as being competent to do the access.
That must have helped a great deal in terms of spreading the procedure to other physicians.
I think the biggest obstacle to doing transradial is the fear, or the lack of confidence that physicians have in terms of gaining radial access. We have been told over the years that it is because of spasms, that it’s very difficult, the arteries are small, the patients move around, and so on. For physicians to see that so many people have become facile with gaining access allows them to be more confident and thus more interested in adopting the technique.
What is your method for gaining radial access?
We use a Cook micropuncture needle and a Terumo Glidesheath kit. Initially, we didn’t even know Terumo existed when I first started transradial. I was using the Cook micropuncture kit and a 5Fr sheath. That facilitated access nearly 100% of the time. The Terumo sheath pack has its own guidewire; we have been using that, but still with the Cook micropuncture needle. I always use front wall techniques.
What happens if you do have a problem upon initial access. Do you jump to the groin at that point?
Absolutely not. If it is spasm, the first thing we do is just step back and take a few minutes. 
We have used a combination of transdermal lidocaine, transdermal nitroglycerin, and also injecting some local nitroglycerin and verapamil in our cocktail right around the radial artery to relieve the spasm. That has been very effective. Even if they spasm initially, which is not very common, in our experience, we have been able to overcome that very easily in almost all our patients. Am I going to say that we’ve never had to change over to a groin? No, of course not. But those patients are very few, fortunately.
In what types of patients are you gaining access radially?
I do everybody.
Including ST-elevation myocardial infarction (STEMI) patients?
Yes. These are my favorites, in fact. The Arkansas Heart Hospital is a tertiary referral care center, and so our STEMI patients are coming from community hospitals. These patients receive thrombolytic therapy and intensive anticoagulation. By doing the procedure radially, we have eliminated a lot of the risk for retroperitoneal bleeds, etc., from the groin. Radial access lets you avoid many of the complications of sticking somebody on anticoagulation.
How many other physicians are doing radial access?
Of our fifteen physicians, about ten are routinely doing radial as their first point of access. The others have gained experience doing it, so everybody now in the group has quite a bit of radial experience.
Have you noticed any cost savings as a result of radial access?
I think from a cost savings perspective, it is about neutral. We do use the Terumo line of 
products. The catheter is a little more expensive than the standard Judkins pack, but since you are only using one catheter, the catheter cost is the same. Certainly, the need for a closure device is eliminated, which, as you know, is not reimbursed, so that is an automatic cost savings. Our personnel also keep track of contrast use, and they have told me we are now using quite a bit less.
The other part of this whole puzzle of cost savings is the fact that when you do a procedure from the transradial approach, no one needs to hold pressure. Patients that have to go the bathroom can get up and go the bathroom. So post-procedural nursing needs are much less, and that has been an enormous benefit from the standpoint of lab throughput. Radial access has also allowed us to do more and more same-day coronary interventions for uncomplicated procedures, and that’s also a cost-saving measure.
What patients do you see as benefitting most from radial access?
It is absolutely a godsend for patients with back pain or back problems, because they don’t have to lay flat for hours post procedure. They can immediately sit up in a chair. We have entertained the idea of a radial recovery room where the people are sitting in recliners, but have not yet implemented it. Certainly, it’s a possibility.
Also, for morbidly obese patients, radial access is wonderful. As our population enlarges, we are seeing more and more morbidly obese patients who need to have cardiac caths. In my mind, these patients are at the highest risk for any kind of groin complication. Doing the procedure radially is actually a pleasure, instead of an endeavor.
As this program has grown, have you seen patient awareness increase?
It has been amazing. When I was first doing transradial, still growing the program, and my other partners had not yet adopted it, I didn’t advertise the procedure as much. However, now we are starting an advertising/ marketing program to let people know that the radial option is available to them at Arkansas Heart Hospital. I have done a few training sessions with physicians in other communities, and have seen them take out full-page ads in the newspapers to let patients in that community know that they were available to do cardiac procedures via the radial approach.
What do patients do after the procedure?
Because of conscious sedation, we have patients to come back to their recovery area prior to ambulating, but at that point, we do not restrict their ambulation post procedure. Uncomplicated diagnostic patients stay about an hour. We have a little hemostasis mechanism, the TR Band, which stays on for an hour, and is then removed. If the patient is ambulating well, they can go home.
We are still evolving in terms of how long we watch a post-interventional patient. Right now, if an uncomplicated stent patient comes in and has a radial intervention, we do keep the TR Band on for 4 hours, and I have been watching these patients for a total of 6 hours, then allowing them to be discharged.
You mentioned using the TR Band. Can you tell us about it?
The TR Band is probably the simplest medical device we have ever used. You just slap it on and it is done. It is a very elegant device. I am not trying to be a commercial salesman for Terumo, but it does work well.
Closure devices can give you a false sense of security. When they work, they work very well. 
However, we have had occasions where patients have looked good initially, and then either an hour or two later, or a day or two later, they have developed groin complications. Closure devices are certainly not 100%. With the TR Band, there is no need to hold pressure, and if you do hold pressure, you just hold the radial artery instead of the femoral.
What has been your experience with transradial complications?
We have had no bleeding complications requiring transfusion in two years. We just do not see any spectacular vascular complications at all.
Any final thoughts?
I think the biggest impediment to converting to a radial approach is the fear of trying something new. We are all feeling so time-pressured to “get through, get through, get through!” Yes, there is a learning curve to gaining expertise in the technique; however, I think that the learning curve is not very steep, and transradial is the future, in my mind. I am at the point where had I trained in an era where radial access was the first line, I would be wondering why I would ever stick the groin. That is how far I have come.
Dr. Rollefson can be contacted at WilliamARollefsonMD@lrcardiology.com
Disclosure: Dr. Rollefson reports a consulting agreement with Terumo Medical Corporation and that he teaches proctoring sessions for the company.
Hospital. The LRCC has two diagnostic cath labs and we perform about 3,000 cases per year. The Arkansas Heart Hospital has five coronary catheterization laboratories and two electrophysiology labs. We do about 7,000 cases/year.
When did you begin the transradial program?
We started it two years ago, after I basically became fed up with growing groin complications. After changing closure devices, and trying different ambulation protocols and catheter sizes, I decided that the only way to avoid groin complications was not to stick the groin in the first place. I came in and said, they are doing radial access in Japan and Germany and India, so why can’t we do it? The staff immediately bought in, and we have been going full bore ever since, to the point where over half of our cases within the group are done radially.
Anytime you try something new, especially if it’s a little bit outside what is routine, you always 
wonder if people will be cooperative or resistant. Our staff has been enormously cooperative and intimately involved in the development of protocols, preps, and just in coming up with new ideas. Everybody participated in developing the process. It has been a very enjoyable experience.
How did you approach training?
We all had some experience with radial access from my internal medicine career and having done a smattering of cases during my fellowship, so I felt comfortable starting out. I also had experience doing a number of brachial access cases. I trained myself, using my experience in both femoral and brachial access. Learning to do radial access is a trial and error process, honestly. I started out with a very gradual approach, doing procedures on middle-aged patients who I felt would be very easy radial candidates. We have a few diagnostic laboratories in our clinic building, and that’s where we actually started doing radial access. I did between 30-40 middle-aged men, and then I started expanding indications. After about 50 diagnostic procedures, I brought radial access over to the hospital, and started doing interventions as well.
How did you train your team?
Three of our staff were very interested in learning radial technique. I had them ‘blaze the trail,’ if you will. We taught them how to prep properly, and even taught them even how to do the radial access. A physician, if he wants to, can always do the access, but our techs are now very adept at gaining radial access on their own.
That is certainly unique!
It was exciting was to see how staff embraced their ability to gain the access for us. It led to a great deal of enthusiasm within the staff and honestly, a little competition to be able to say, hey! I can do this as well. Our staff has been doing groin access for years. Most tell me it is easier to stick the radial artery than it is to stick the femoral artery. I did require them to train with me to understand the anatomy. They had to do a number of directly supervised accesses so I could sign them off as being competent to do the access.
That must have helped a great deal in terms of spreading the procedure to other physicians.
I think the biggest obstacle to doing transradial is the fear, or the lack of confidence that physicians have in terms of gaining radial access. We have been told over the years that it is because of spasms, that it’s very difficult, the arteries are small, the patients move around, and so on. For physicians to see that so many people have become facile with gaining access allows them to be more confident and thus more interested in adopting the technique.
What is your method for gaining radial access?
We use a Cook micropuncture needle and a Terumo Glidesheath kit. Initially, we didn’t even know Terumo existed when I first started transradial. I was using the Cook micropuncture kit and a 5Fr sheath. That facilitated access nearly 100% of the time. The Terumo sheath pack has its own guidewire; we have been using that, but still with the Cook micropuncture needle. I always use front wall techniques.
What happens if you do have a problem upon initial access. Do you jump to the groin at that point?
Absolutely not. If it is spasm, the first thing we do is just step back and take a few minutes. 
We have used a combination of transdermal lidocaine, transdermal nitroglycerin, and also injecting some local nitroglycerin and verapamil in our cocktail right around the radial artery to relieve the spasm. That has been very effective. Even if they spasm initially, which is not very common, in our experience, we have been able to overcome that very easily in almost all our patients. Am I going to say that we’ve never had to change over to a groin? No, of course not. But those patients are very few, fortunately.
In what types of patients are you gaining access radially?
I do everybody.
Including ST-elevation myocardial infarction (STEMI) patients?
Yes. These are my favorites, in fact. The Arkansas Heart Hospital is a tertiary referral care center, and so our STEMI patients are coming from community hospitals. These patients receive thrombolytic therapy and intensive anticoagulation. By doing the procedure radially, we have eliminated a lot of the risk for retroperitoneal bleeds, etc., from the groin. Radial access lets you avoid many of the complications of sticking somebody on anticoagulation.
How many other physicians are doing radial access?
Of our fifteen physicians, about ten are routinely doing radial as their first point of access. The others have gained experience doing it, so everybody now in the group has quite a bit of radial experience.
Have you noticed any cost savings as a result of radial access?
I think from a cost savings perspective, it is about neutral. We do use the Terumo line of 
products. The catheter is a little more expensive than the standard Judkins pack, but since you are only using one catheter, the catheter cost is the same. Certainly, the need for a closure device is eliminated, which, as you know, is not reimbursed, so that is an automatic cost savings. Our personnel also keep track of contrast use, and they have told me we are now using quite a bit less.
The other part of this whole puzzle of cost savings is the fact that when you do a procedure from the transradial approach, no one needs to hold pressure. Patients that have to go the bathroom can get up and go the bathroom. So post-procedural nursing needs are much less, and that has been an enormous benefit from the standpoint of lab throughput. Radial access has also allowed us to do more and more same-day coronary interventions for uncomplicated procedures, and that’s also a cost-saving measure.
What patients do you see as benefitting most from radial access?
It is absolutely a godsend for patients with back pain or back problems, because they don’t have to lay flat for hours post procedure. They can immediately sit up in a chair. We have entertained the idea of a radial recovery room where the people are sitting in recliners, but have not yet implemented it. Certainly, it’s a possibility.
Also, for morbidly obese patients, radial access is wonderful. As our population enlarges, we are seeing more and more morbidly obese patients who need to have cardiac caths. In my mind, these patients are at the highest risk for any kind of groin complication. Doing the procedure radially is actually a pleasure, instead of an endeavor.
As this program has grown, have you seen patient awareness increase?
It has been amazing. When I was first doing transradial, still growing the program, and my other partners had not yet adopted it, I didn’t advertise the procedure as much. However, now we are starting an advertising/ marketing program to let people know that the radial option is available to them at Arkansas Heart Hospital. I have done a few training sessions with physicians in other communities, and have seen them take out full-page ads in the newspapers to let patients in that community know that they were available to do cardiac procedures via the radial approach.
What do patients do after the procedure?
Because of conscious sedation, we have patients to come back to their recovery area prior to ambulating, but at that point, we do not restrict their ambulation post procedure. Uncomplicated diagnostic patients stay about an hour. We have a little hemostasis mechanism, the TR Band, which stays on for an hour, and is then removed. If the patient is ambulating well, they can go home.
We are still evolving in terms of how long we watch a post-interventional patient. Right now, if an uncomplicated stent patient comes in and has a radial intervention, we do keep the TR Band on for 4 hours, and I have been watching these patients for a total of 6 hours, then allowing them to be discharged.
You mentioned using the TR Band. Can you tell us about it?
The TR Band is probably the simplest medical device we have ever used. You just slap it on and it is done. It is a very elegant device. I am not trying to be a commercial salesman for Terumo, but it does work well.
Closure devices can give you a false sense of security. When they work, they work very well. 
However, we have had occasions where patients have looked good initially, and then either an hour or two later, or a day or two later, they have developed groin complications. Closure devices are certainly not 100%. With the TR Band, there is no need to hold pressure, and if you do hold pressure, you just hold the radial artery instead of the femoral.
What has been your experience with transradial complications?
We have had no bleeding complications requiring transfusion in two years. We just do not see any spectacular vascular complications at all.
Any final thoughts?
I think the biggest impediment to converting to a radial approach is the fear of trying something new. We are all feeling so time-pressured to “get through, get through, get through!” Yes, there is a learning curve to gaining expertise in the technique; however, I think that the learning curve is not very steep, and transradial is the future, in my mind. I am at the point where had I trained in an era where radial access was the first line, I would be wondering why I would ever stick the groin. That is how far I have come.
Dr. Rollefson can be contacted at WilliamARollefsonMD@lrcardiology.com
Disclosure: Dr. Rollefson reports a consulting agreement with Terumo Medical Corporation and that he teaches proctoring sessions for the company.
