When the Clinical Advocacy Message Hits Home: A Terumo Sales Representative Requests Transradial Intervention for Two Family Members

Monday through Friday, and sometimes on weekends, I find myself in my south Florida cath labs engaged in clinical discussions, product evaluations and, more often, performing an in-service on transradial access. I am fortunate and grateful that my territory has embraced this strategy, growing from one cath lab doing transradial procedures when I first began, to 11 cath labs engaged or in-process today. The words fortunate and grateful are carefully chosen, as this year, both my father and father-in-law underwent coronary interventions within a week of each other. It was strange to go from a 100% clinical role to that of a family member, and experience all of the accompanying emotions. I remembered my father’s first percutaneous coronary intervention (PCI) experience. I knew my clinical training. What was best for him? Will the doctor support the request? As certain as I was of my knowledge and experience, something changes when the patient is someone you know and love. Advocating for my father… In January 2009, my father suffered an acute myocardial infarction (MI) while we were attending a family wedding. He was taken to the closest hospital, where he entered through the emergency room. The attending physician used a standard femoral approach and placed two bare metal stents, one in the left main and one in the left anterior descending artery (LAD) at the bifurcation. The procedure was a success, but during recovery, my father experienced a significant hematoma that extended from his thigh to his belly. He remained in the hospital for five days, two of which were due to severe pain resulting from the hematoma. An ultrasound was performed to check for a potential pseudoaneurysm at the entry site. Following his discharge, my father remained off work for two weeks. What my father remembers most from this experience was the severe pain he felt post procedure and his inability to go back to his normal routine for two weeks after treatment. At his six-month follow-up visit, my father underwent a full work up. He had a positive stress test and his doctor recommended a diagnostic catheterization. Given my father’s medical challenges, including obesity, diabetes and high blood pressure, as well as his prior hematoma, I asked his doctor about the possibility of, and our preference for, a transradial approach. While the doctor had not performed many transradial cases, he was familiar with the procedure, having observed a number of cases performed by one of his associates. He agreed to a transradial approach. It turned out that my father had restenosis at the site of the prior intervention and received a drug-eluting stent. Unlike the first procedure, and thanks to the transradial approach, my father was up and walking within hours. He was discharged the following morning. By that afternoon, he was back at work. If you ask my father to compare his two experiences, he would tell you that without a doubt that the second was less painful and he recovered much quicker. Next, advocating for my father-in-law… In April 2009, while on a joint family vacation, I noticed that my father-in-law was easily fatigued and was unable to join in many activities that had never given him pause in the past. To look at him, he appeared to be in excellent shape. He shared with me privately that he was tired and his chest felt tight, with some discomfort up through his jaw. I encouraged him to see his doctor, as I explained that these symptoms were not normal and potentially a problem. He took my advice and contacted his primary care physician. On July 17, he completed a battery of tests, including blood, stress test, echocardiogram and electrocardiogram. The stress test was positive. On August 4, 2009, one week after my father left the hospital, we found ourselves at the emergency room at the University of Miami Hospital. My father-in-law, who does not speak English, was moved quickly to the cath lab and put in the care of Dr. Mauricio Cohen, Associate Professor and Medical Director of the Cath Lab at the University of Miami Hospital, University of Miami Healthcare System, Miami, Florida. While many of the hospital’s personnel are bilingual, I frequently found myself in a unique position of family member and translator. There was no question in my mind that Dr. Cohen would opt for transradial access. I was greatly comforted by his knowledge and skill with this procedure. Dr. Cohen started with a left diagnostic cath and saw a mild LAD stenosis. He then flipped the same catheter, selectively engaged the RCA and discovered the culprit lesion. The RCA was diffusely diseased with a 95% lesion in the mid segment and a 100% chronic total occlusion in the distal segment, though there was some collateral flow (Figures 1-3). Dr. Cohen placed four drug-eluting stents — two 2.5 x 24 mm and one 3 x 30 and one 3.5 x 30 mm; a full metal jacket via transradial access. My father-in-law was kept overnight for observation. The next morning, he had an echocardiogram, electrocardiogram and ultrasound. There were no problems and he was discharged that day. My father-in-law is recovering beautifully. Practicing what I preach… I definitely believe in practicing what I preach. I have seen the clinical challenges brought on by femoral sticks that go wrong and recognize patient profiles that can benefit most from transradial access. I also believe that the patient experience is generally more positive with transradial access than it is with transfemoral access and that patients always ambulate faster. Over the past year, I have seen growing support for transradial access in my sales territory and in the United States. It was only natural for me to want my father and father-in-law to have the very best experience and outcomes. I am certain that transradial access was the right choice for both. More importantly, so were they.

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