The Final Frontier for Peripheral Access

Peripheral lower extremity interventions have traditionally been performed from the contralateral groin approach. Later, other access sites were used. Antegrade access was used as it provided better support and better reach in the foot compared with contralateral retrograde femoral access.

As a result, it became easier to perform interventions on pedal loop with the existing length of equipment. However, groin access still had some drawbacks, including increased risk of bleeding from either failure of hemostasis due to patient movement or failure of closure device, patient discomfort from lying flat for many hours, and delayed ambulation.

Pedal access using the anterior tibial artery or posterior tibial artery was later used. Pedal access provided the benefit of fewer bleeding complications and early ambulation, but patients with critical limb ischemia and patients with ulcers had extremely diseased vessels, which made access with ultrasound more difficult. Usually only one infrapopliteal vessel could undergo intervention using with this method. Brachial access also had the drawback of possible brachial artery occlusion and threatened the limb with digital gangrene after the procedure.

It seemed that none of the access options for peripheral intervention was clearly superior in terms of benefits. However, radial access for peripheral intervention appears to be the emerging best solution. In my opinion, it will change the way peripheral interventions are done. It is the next and hopefully the final frontier for peripheral access.

The benefits of radial access include reduction in bleeding complications and infection rates, as well as increased patient satisfaction due to rapid ambulation and reduced length of stay. These advantages result in reduced costs for the facility, the ability to perform intervention on more than one infrapopliteal vessel, and the relatively disease-free anatomy of the radial artery facilitating easy access. Additionally, radial closure bands applied after procedures are well known and easy to use as a result of their widespread coronary use. The access bands are usually removed in 1 to 2 hours and the patient can be discharged home afterwards.

All areas of medicine are interested in improving patient safety, especially considering the growing list of “never events” from Centers for Medicare and Medicaid Services. In the cath lab, physicians are looking for ways to reduce complications, and one method is radial access instead of femoral access for peripheral interventions.

Radial access should decrease the need for stretchers in the recovery room. In fact, we may need to create a “transradial access recovery lounge” in which beds are replaced with chairs and patients are encouraged to walk around, get coffee, check their e-mail, and read. This type of setting for recovery should also ease the nursing acuity in post-operation patients since the groin is not being used. Radial access greatly improves patient comfort. Patients do not have to stay in bed; they can sit up to eat, and they can walk to the bathroom. These factors alone significantly reduce the amount of nursing care necessary for each patient.

Various companies have supported radial access with the devices they produce. Terumo produces specialized radial access devices, including a destination Slender sheath that comes in 2 sizes of 119 cm and 149 cm and that reaches the common femoral artery in the shorter version and popliteal artery in the longer version. Along with the destination sheath, long glidewires are available from 350 cm to 450 cm in stiff and standard versions. Cardiovascular Systems Inc will also release their CSI Diamondback device in 200 cm shaft length with a 475 cmViper wire that can perform rotational atherectomy up to mid infrapopliteal vessels. In addition, balloon lengths are available from 180 cm to 200 cm shaft length, which provide easy reach to the mid infrapopliteal vessel.

There are some drawbacks regarding radial access. The available destination sheath is 6 Fr and larger catheters or devices may still require the femoral approach. Also, radial loops can make the anatomy unfavorable. Another drawback is non-availability of all devices, including crossing catheters, other atherectomy devices, drug-coated balloons with longer shafts, and stents with shafts greater than 150 cm.

Nonetheless, I feel that technology will soon meet our needs and allow us to realize the immense benefits provided by radial access, and it is only a matter of time until we can perform most, if not all, peripheral interventions with radial access. Radial access should also be the preferred access method in various office-based labs where early ambulation and discharge is greatly desired.Various hospital organizations will also be looking at its benefit in early discharge and greater patient satisfaction scores. If you ask patients who have had procedures femorally and radially, there is no question as to which method they will prefer.