Sheathless in New Orleans
Since its inception the casual mantra of interventional radiology has been, “If it ain’t broken, don’t fix it.” As a corollary if it is broken, fix it with minimal trauma and return the patient to productivity as soon as possible.
To carry out this agenda, interventionalists led the charge early on by utilizing finesse and skill to reduce the size of catheters and needles. Theoretically, this means smaller size, less trauma, fewer complications, and quicker recovery.
Recently, however, the complexity of the procedures has skyrocketed and the "smaller is better" philosophy has often lost out to potentially easier performance. For example, vascular sheaths can make catheter manipulation easier and provide more comfort to the patient in the event of multiple exchanges. Additionally, the larger arterial hole caused by sheaths can be remedied with closure devices and the patient can ambulate sooner. Despite the additional cost and rare but real complications, these devices have become almost routine in many venues, especially interventional oncology where many are attempting to discharge the patient the same day.
There is, however, an alternative method which maintains the "smaller is less traumatic" philosophy. Using a 4 Fr catheter with a .038” end hole permits performance of the diagnostic portion of an interventional oncologic procedure. Additionally, 4 Fr catheters can more readily be placed in larger branch vessels providing better imaging than their smaller microcatheter counterpart. The 4 Fr .038” end hole catheter can accommodate high flow microcatheters that can be placed peripherally and used for chemo or bland embolization. The mother catheter is rarely exchanged and acts as the sheath but at a much lower profile. Moreover, both interventional radiologists and cardiologists at the University of Florida independently have demonstrated that when using a 4 Fr catheter, patients can ambulate after 2 hours using simple manual compression for hemostasis. I personally have gone sheathless in greater than 50 interventional oncologic procedures with 80% success. The 20% requiring a sheath included mostly vasculopaths with advanced plaque and/or multiple interventions.
Going sheathless with a 4 Fr catheter permits patients to ambulate early without the cost in dollars and potential complications of closure devices. Yes, at times it does require more skill, but isn’t that the keystone of our specialty?
