Two Transradial Experts, Two Perspectives, One Course

Dr. Tai and Dr. Sizemore offer a regular course in Florida for physicians interested in learning radial technique. Technologists can also attend to learn about transradial equipment, prepping the patient and proper setup. Courses have been scheduled for February, March and April 2010.

Dr. Zaheed Tai

Tell us about the cath lab at Winter Haven Hospital. We have three labs. Two are used for coronary and peripheral interventions. The third lab is a diagnostic lab and is used for electrophysiology procedures. Winter Haven Hospital is a not-for-profit community hospital. What is your procedure volume? My personal volume is probably about 10-12 cases a week on average. In the busy “snowbirds” season, November to April, it could be upwards of 15-20 cases in a week. It slows down in the summer. How many other physicians are using the cath labs at Winter Haven? There are four interventionalists and three diagnostic physicians. Three of the four interventionalists are transradial operators and the fourth wants to learn, so we are helping him along. The three diagnostic doctors want to learn transradial as well, so Dr. Sizemore and I plan to do an in-house course and training for those four physicians. Tell us about your transradial training. I did my training in New York at St. Vincent’s Hospital under Dr. John Coppola*. In 2003, St. Vincent’s made a decision to transition to a transradial program. During my fellowship I learned the transradial technique and was practicing in New York for four years prior to moving to Winter Haven. Dr. Sizemore was doing some transradial procedures before I came to Winter Haven. He was running into some obstacles because the lab didn’t want to make the transition. They weren’t really on board with it, but when I came, there were now two physicians who wanted to do transradial access. We started to make Winter Haven a transradial program. I do probably about 90% of my cases with the transradial approach, including some peripherals. Among the transradial operators, we have done approximately 90% of our STEMIs via the radial approach. In an acute MI, you don’t want to waste any time upsizing your sheath, so we just use a 6Fr from the start in a true ST-elevation MI. With the new Terumo Glidesheath, the incidence of any vascular complication between 5 and 6 Fr is not significant in our experience. What has changed since you learned the transradial technique in 2003? I have accessed the same way for the last 6 years, since I first learned. It’s been more of a change in equipment than access technique. The sheaths are now designed for transradial access. The Terumo Glidesheaths have a lubricious coating, which makes things a great deal easier. There are also more dedicated catheters for doing radial angiography. There were not so many of those available 6 years ago. More dedicated guides are coming out for transradial intervention as well. Have you had patients referred to you specifically for the transradial approach? Yes. Sometimes it is because the patient has requested it, because in this community, patients talk to each other. I’ve even had patient referrals from other cardiologists who have interventionalists in their group, because the patient wanted their procedure done by a transradial approach. It’s a nice marketing tool. Are they marketing transradial at any other way at your hospital? The hospital has been in the newspaper and advertised that Winter Haven cath lab is a transradial program. CLD heard from a staff member who was upset about experiencing some longer procedures while their physicians were learning the transradial technique. As with any procedure, there is a learning curve at the beginning. As you start doing more diagnostics, after about 100 or more, procedure times go down and approach femoral access times. When you look at procedure times or acute MI times of experienced transradialists, such as Dr. Sizemore and myself, you will see that there has been no sacrifice in procedure times or door-to-balloon times. Part of the learning curve does involve the setup. Other hospitals in the area have wanted to do some transradial work, and they haven’t bothered, in my mind, to do the correct setup. They do a makeshift setup and I’ve heard from some of the staff that rotates in both labs that it is not comfortable for the physician and it’s not good to work with for the staff. If you’re going to do it, you have to make a serious commitment. You have to make a serious commitment, you have to stick with it, and not get frustrated at the very beginning. Like with anything, it’s not going to be smooth at the very beginning. Be more selective with your cases, but try and do as many as you can. Don’t just do one or two a week. Pick a day or two and say, I’m going to try and do three or four transradial cases today. Don’t wait for the 350-lb patient where you don’t want to stick the groin. It’s in the best interest of the lab and staff to learn the proper setup, how to position the arm, how to position the hand, where the equipment should be, and what the right equipment is to help facilitate access. If you are not successful in your first or second attempt at access, you can end up causing spasm, and having to abort the procedure or wait for the spasm to subside. That can lead to delayed times, so not having the right equipment to do arterial access can make a difference as well. How did you and Dr. Sizemore begin your transradial teaching course? Terumo approached us after seeing a spike in volume here in radial procedures, particularly for central Florida. I believe Winter Haven Hospital is the busiest transradial procedure center in central Florida. My connection to Dr. Coppola came up — he teaches a hands on transradial course at St. Vincent’s in New York which is extremely popular. We wanted to teach a transradial course in Florida much like the one at St. Vincent’s. Our course is a hands-on course for Florida residents only, because unfortunately, Florida doesn’t grant temporary licenses to out-of-state physicians (but out-of-state people can come and observe). The course is for both technologists and physicians. We have had lab techs in the course who have learned how to set up the lab and prep the patient. For physicians, we go through access and diagnostic angiography. We try to book 6-8 cases each and limit the course to four physicians. This ensures that each person will get a decent amount of hands-on time with access and catheter selection. One advantage to our training program is that Dr. Sizemore and I use two different approaches to do transradial access, so attendees get experience with both of our access techniques. We access differently as well as use different catheters. He tends to use more dedicated catheters, the Terumo Jacky, the TIG catheter or the Boston Scientific Kimny catheter, for his diagnostics. I use the standard JL3.5 and JR4 for the majority of my cases. It gives the participants a broad exposure over a single day to different techniques for transradial access. We’ve had positive feedback from everyone who has participated. Most have gone back and made an effort to transition their labs into transradial-based programs. Regarding the staff member you mentioned who was concerned about procedure times, I think there is some hesitation from lab staff regarding time and setup. When the techs have come to our lab and learned how quickly it can be done, it has made it easier for their physicians to go back to the program and say, this is what we, as a team, want to do. Now they have someone with the experience to help them set up the lab as well. Other operators have said that once staff is on board everything becomes much easier. Right. When I came to Winter Haven in March 2008, the issue was that the staff was not truly on board. I refused to do femoral and in that way, forced the issue of making a commitment to transradial. Orlando Marrero, RCIS, our chief technologist, also wanted to do it and was very quick to say okay. I think our staff just needed someone to push the issue a little more. Orlando got everyone onboard. If you talk to hospital staff and patients today, they are thrilled. The CCU staff loves it, because they don’t have to worry about groin pulls. It allows for quicker turnover in the lab, because there are no access site issues (hematomas, closure failure) before we transition someone from the holding area to the room. We pull the sheath on the table, and either put a pressure dressing or a TR Band on the wrist. The patients sit up and then go back to their rooms. The patients love it too. Everybody is happy with transradial access. What is your experience with bleeding complications? Fortunately, we have experienced no major bleeding complications. There have been a couple patients where the pressure dressing or the TR Band was not accurately positioned or removed too early, and patients who were on IIb/IIIa inhibitors developed large ecchymosis, but no one has had a compartment syndrome, a perforation of the artery from traumatic injury, or any major injuries requiring surgery or a transfusion. While I was in New York, I worked in a few diagnostic labs as well as interventional labs. The diagnostic labs didn’t have the luxury of having cardiology fellows to check on patients. The last thing you want to do is leave the hospital and get called back because a patient is hypotensive. When that happens you have to send the patient for a CT, because you’re worried about a retroperitoneal bleed and whether there is a problem with the groin. With the transradial approach, there is no problem with the groin. You pull the sheath and put on the pressure dressing. By the time you are done with your paperwork, you will know if there’s a problem with the pressure dressing or the TR band. When you leave the hospital, you’re not worried about having to come back to address a retroperitoneal hematoma or groin hematoma. When you do a very complex procedure and want to keep your IIb/IIIa inhibitor on board, you don’t have to worry about stopping it secondary to an access site issue. Meanwhile, with the femoral approach, you could be called half an hour later because the groin is oozing, the patient is hypotensive or there’s a hematoma, and the IIb/IIIa inhibitor has to be shut off after you’ve spent time revascularizing a CTO, treating an acute MI or a bifurcating lesion. Do you see some degree of tortuous anatomy? The other day, we actually had one person with two loops in their brachial artery and we were not able to do that particular patient via radial access. Once we straightened it out there was too much spasm. Occasionally, you do encounter anatomical issues, but this represents less than 10% of cases. Sometimes you will get patients who have some tortuosity. If you can get through it, put in a long sheath to avoid having to do multiple transitions through that area and worrying about spasm. I don’t think it’s a huge issue in most patients. What if the patient needs a more complex intervention than expected and you have to convert to groin access? It all depends on the patient. We successfully use a 6Fr catheter on nearly 100% of patients. It is possible to do bifurcating lesions and chronic total occlusions through a 6Fr catheter. For some of the men, you can use 7Fr and I’ve even used an 8Fr. There are certain times, particularly with chronic total occlusions (CTOs), where you may not get adequate guide support from a radial approach even if you can use a 7Fr system. That’s probably because the catheters just aren’t dedicated for a radial approach. If you had a very, very complex CTO, you may not be able to cross from a radial perspective, or maybe you can cross, but not deliver a stent. The patient may be better served going with a larger catheter from femoral access. We have used a 6Fr in some small female patients, and were able to cross the CTO, but couldn’t really get anything down the vessel because of inadequate guide support and despite debulking with either rotational atherectomy or excimer laser. We had to bring them back for a femoral approach, and were subsequently successful in the revascularization. So that does happen, but again, you are talking about a small percentage of cases. Do you do any peripheral work from a radial approach? Yes, we do renal arteries, iliacs and occasionally carotid angiograms from the transradial approach. If you talk to experienced radial operators, this is not uncommon. We mostly do renal arteries from the left radial, as well as iliac arteries. The problem with doing anything further is the equipment. It’s not feasible in bigger patients because most of the equipment is designed with the length at 135 cm, and you can’t get beyond the iliacs to do superficial femoral artery (SFA) work from a radial approach. We do diagnostic peripheral angiograms in patients with severe peripheral arterial disease from the radial approach and then we stage these patients for the best approach. We can determine that based on the angiography as well as confirm or refute noninvasive findings, with little risk from the radial approach. Has incorporating a high percentage of transradial procedures had a financial impact on the lab? The lab is able to turn over the room much quicker, so it allows us to do more cases in a day. We can do same-day discharge on simple percutaneous coronary interventions without having to worry about bleeding complications. Granted, you can do that with femoral access, too, but I think there is always a small fear that something could happen to the groin a couple hours after discharge. That’s part of the reason why we keep patients overnight when we use a femoral approach. Dr. Tai can be contacted at zaheedtai@gmail.com

Dr. B. Clay Sizemore

What is your background with the transradial procedure? I was trained during my fellowship at the University of Florida where we did transradial catheterization on a very limited basis — as needed for obese patients or patients with peripheral arterial disease. When I came out of my fellowship, I joined the staff of Winter Haven Hospital. The cath lab staff and I agreed to a policy of doing a minimum of a few cases per week to keep facile with our skills. Then, when Dr. Tai joined the staff with his enthusiasm for transradial, we jointly decided to transition the lab to a default approach of radial access. What’s your perception of how many fellows receive this type of training? It’s hit or miss. It would seem that the large majority of fellowship programs do not offer adequate transradial exposure. There are certainly some centers of excellence. I know there is a great deal of interest from fellows across the country in getting trained. We’ve actually had several participants in our course that are recently graduated interventional fellows. With the recent resurgence of interest, including several calls from interventional thought leaders to expand fellows’ opportunities in transradial intervention (TRI), I suspect many training programs will step up and evolve that part of their curriculum. Why do you like the transradial approach? It comes down to two primary reasons, patient satisfaction and safety. I like it because my patients like it. I like it because it has been clearly associated with less bleeding and access site complications. There is a growing awareness of the major impact bleeding complications have on short and long-term outcomes. Can you share more about your method of gaining access and how it differs from Dr. Tai? We do have different methods of gaining access and we use different catheters. I would say that both of our techniques are grounded in well-established practices and we have similar approaches to patient selection, as well as knowing when to abort transradial access and when to defer back to alternative access (the groin, brachial, etc.). That being said, he prefers a true Seldinger or “through and through” technique with an Angiocath, while I tend to utilize a modified or “front-wall” stick with a 21-gauge needle. There are advantages and drawbacks to each, so we allow participants to try both and then go with whatever feels right for them. Do you have patients’ groins prepped when doing transradial access? We generally will prep at least one groin site for emergency purposes only. We don’t really give patients the option of not prepping the groin. How often are you converting to femoral access? Our conversion rate for acute MIs is very low, less than 5%. How do you determine what patients should not get the transradial approach? We have a strict protocol, which is that every patient has a full assessment of all of their peripheral pulses, particularly the intended access site. The radial and ulnar pulses are examined. They must have a palpable ulnar pulse and intact arch as documented by the Allen’s test. The staff has become very proficient. Patients must have a reasonably sized wrist, although I can count on two hands the number of cases where I have deferred radial access because they were too small. It is rare that patients are so small that we are concerned about tolerance of a 5Fr sheath. Radialist Dr. Craig Thompson has mentioned the access point on the wrist, saying that those new to the procedure might go a little too high or low as a common mistake. There is the temptation to an untrained or inexperienced operator to stick lower because the pulse is more superficial and can be felt more easily. The problem arises from a fibrous band at the wrist called the flexor retinaculum. If you stick too close to this ligament, you can create a compartment syndrome, even with minimal bleeding or swelling. Our general technique is to stick about two finger breadths proximal to the scaphoid. What are some of the other things that inexperienced operators might do that you see in your course? Depending on your choice of equipment, there is a learning curve in terms of using nontraditional catheters. Dr. Tai will generally use traditional-shaped catheters like JR or JL catheters. If you use the Optitorque line of dedicated radial catheters by Terumo, those are non-conventional shapes that do require some practice in terms of manipulation, although they are specifically designed to be easy to manipulate, and importantly, minimize catheter exchanges, thereby saving time and reducing the risk of stroke. It’s just a different maneuver than what is taught for femoral access. Also, when you are working with a smaller artery and smaller wire, particularly in older, smaller people, there is a tendency sometimes to go too fast, which increases the incidence of spasm and/or in rare situations, perforation. Fortunately, these are generally manageable situations, though nonetheless to be avoided. How do you handle transradial patients post procedure? I have had great success with the Terumo TR Band for transradial hemostasis. It is easy to apply and allows excellent visualization of the puncture site. Generally, patients will sit up immediately and shift themselves over to a gurney, on which they are taken back to the preoperative holding area. We typically allow them to recover for a brief period of time, because they still do get some light conscious sedation for anxiety (not for discomfort); then they can ambulate as needed. Diagnostic-only procedures are discharged around two hours post-procedure. I am currently, with rare exception, keeping coronary intervention patients overnight, but we have begun development of protocols for same-day discharges for low-risk cases. What’s been your experience with complications with the transradial procedure? Spasm is the most frequent complication and is generally very easily overcome or spontaneously resolves. Bleeding complications are exceedingly rare, and despite our reasonably high-volume experience, they are limited to small hematomas and ecchymoses thus far, with no major residual long-term effects. We know from the literature that a small fraction of cases will go on to lose the radial pulse, but this has never been correlated with clinical problems. How often do you and Dr. Tai present your course? We’ve gone from doing a quarterly course to every other month or so, and have discussed going monthly because of the overwhelming interest. We’ve been doing the course for almost a year now. There has been a marked increase in interest level. The course is intentionally kept intimate and small, because it is a hands-on course. We don’t want to have participants standing and waiting, so we limit the course to 3-4 participants and the spots fill up quickly. Participants arrive the night before or early on the day of the course, and spend the full day with us. We do a minimum of 6-8 cases each, so we provide a total of 16 patient contacts. There is also a didactic component consisting of about 90 minutes of relaxed discussions and case reviews, which occurs either the evening before or that day, depending on participant traveling schedules. Can you talk about the learning curve? The learning curve is definitely real, but it is frequently exaggerated. My experience is indicative of the fact that a fellowship with a high volume of radial exposure is not necessary in order to transition to a default transradial program. The learning curve, unfortunately, is sometimes a stumbling block in terms of motivation. That’s one of the things we are trying to convey to participants. Radial access is very doable for anybody with reasonable catheter skills, with just a little bit of exposure. Dr. Tai and I get a lot of the credit for having an active and successful transradial program at Winter Haven Hospital, but it is actually the staff that have really embraced it as an approach and seen the benefits. They have made it possible to develop this program and have contributed many of the modifications we have made in patient preparation and work flow. We very much credit them with a large portion of our success. For labs across the country interested in the transradial technique, getting that kind of investment from the staff would be very beneficial. Dr. Sizemore can be contacted at bcsizemore@yahoo.com.

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