Radial access intervention presents a surprisingly steep learning curve at teaching hospitals newly undertaking the approach, according to research presented at the Society of Cardiovascular Angiography and Interventions (SCAI) Scientific Sessions on May 5, 2010, in San Diego, CA.
But another study from the SCAI conference points out that, on the plus side, radial access can enable patients to be discharged on the same day as treatment.
New Radial Access Program Demands Persistence
To better understand barriers to transradial PCI in the United States, Michael Lim, MD, and colleagues at St. Louis University (St. Louis, MO), adopted the technique in their outpatient catheterization lab in July 2009. The program involved 3 interventional cardiologists and 8 senior fellows. Radial access intervention was attempted in all patients except those with an abnormal Allen’s test, end-stage renal disease requiring dialysis, previous bypass surgery, or the need for combined right and left heart catheterization.
The initial 53 transradial procedures were compared against matched historical controls treated via femoral access at the same center. No vascular complications occurred in either group. While the number of catheters used was similar for both strategies, the radial approach required significantly longer time to establish access and longer fluoroscopy duration. There was also a trend toward lower rate of procedural success with radial access (table 1).
Table 1. Outcomes with Radial vs. Femoral Approach
|
Radial
(n = 53)
|
Femoral
(n = 53)
|
P Value
|
Number of Catheters Used, mean
|
2.8 ± 1.8
|
3.04 ± 0.2
|
NS
|
Time to Establish Access, mins
|
7.57
|
4.17
|
0.002
|
Fluoroscopy Time, mins
|
10.01
|
4.07
|
0.003
|
Procedural Success
|
83%
|
96%
|
NS
|
These differences show that “in a teaching center, the learning curve for adoption of newer techniques is significant,” the investigators conclude, adding, “It is unclear to what extent the expertise of the attending cardiologists may mitigate the steep learning curve of the fellows in [transradial access] catheterization.”
In a telephone interview, Dr. Lim said that the results should not dissuade PCI centers from adopting the technique. “The reality is that radial access is a cultural change to cardiac catheterization,” he told TCTMD, adding that such shifts do not come easily but are worthwhile when done for the right reasons. “If the published data [are correct], there is a clear and definite safety benefit for patients, and there’s a clear comfort factor for patients, too.”
“This study just points out [to program directors or cath lab directors] that . . . you have to stick to your guns and be committed. This is not a quick transition,” Dr. Lim said. “I think that radial artery access should be taught and should become part and parcel for all future cardiologists performing cardiac catheterization procedures.” Not only should the interventional cardiologists and fellows be on board, so should the nurses and technicians, he advised, “because they end up spending more time with the patients than the physicians do, when you count preparation before the cath and recovery after the cath.”
‘A Higher Responsibility’
Previous studies have shown a learning curve of about 50 cases at institutions without fellows, Dr. Lim reported. “We’re teaching the next generation of cardiologists to do procedures. They’re the least experienced, and when we allow them to get arterial access and manipulate catheters . . . that by definition makes cases go longer,” he said, adding, “It’s a higher responsibility and more difficult and challenging environment for sure, but if we teach [the approach], we’ll have more experienced radial operators in the pipeline.”
Now, all patients seen in the cath lab at St. Louis University Hospital are evaluated for both radial and femoral access, with radial being the default strategy, Dr. Lim said. Exclusions are patients on dialysis, those undergoing planned procedures requiring a larger sheath (8 Fr), and those who fail the Allen’s test prior to PCI.
Same-Day Discharge an Option
In a separate study, researchers led by Ian C. Gilchrist, MD, of Penn State College of Medicine (Hershey, PA), determined that contrary to a 2009 SCAI consensus statement cautioning against same-day discharge after most PCI cases, radial access lowers bleeding risk sufficiently enough that outpatient procedures may be an option.
Just after publication of the SCAI document, Dr. Gilchrist and colleagues examined the previous 100 consecutive patients who underwent elective PCI performed via radial access and were discharged the same day from Milton S. Hershey Medical Center (Hershey, PA), a practice with 10 years of radial PCI experience. All patients were offered the possibility of an overnight stay but none accepted. After treatment, there were no readmissions, postprocedural complications, or problems specifically attributable to early discharge.
The majority of the cohort (n = 100; 85%) had contraindications to same-day discharge according to the SCAI expert consensus, including:
- Age > 70 years (n = 26)
- LVEF < 30% (n = 3)
- eGFR < 60 mL/min (n = 1)
- Insulin-dependent diabetes (n = 5)
- Contrast allergy (n = 4)
- Medically-treated chronic obstructive pulmonary disease (n = 8)
- Multivessel coronary disease (n = 4)
- Peripheral vascular disease, congestive heart failure, or prior heart transplant (n = 6)
- Living ≥ 20 miles from hospital (n = 62 patients; median 54 miles)
- Complex PCI (n = 23; 5 left main disease, 2 grafts, 12 proximal LAD, 2 multivessel disease)
- Intravenous GP IIb/IIIa inhibitor used, not pretreated with clopidogrel (n = 52)
Thus, discharge criteria based on procedural success rather than baseline characteristics can adequately define a patient population suitable for early discharge, the researchers conclude.
Dr. Gilchrist told TCTMD in a telephone interview that same-day discharge is a common practice in Europe and other regions where radial access PCI is widely used. “It’s something that goes along with the radial procedure. You’ve taken a procedure that had real bleeding risks and changed it into a procedure that is not much different than going to a dentist and getting your teeth cleaned,” he said. “It’s something you don’t want to do, but when it’s all said and done you wonder what you were so worried about.”
In an e-mail communication, Olivier F. Bertrand, MD, PhD, of Hôpital Laval (Quebec City, Canada), agreed that radial access speeds recovery such that there is no need for bed rest. “With radial access, hemostasis usually takes 2 hours and the risk of complications is very limited, so the majority of patients can be discharged home or to the referring hospital within 4 to 6 hours,” he commented to TCTMD. Dr. Bertrand pointed out that the EASY (EArly Discharge after Transradial Stenting of CoronarY Arteries) trial demonstrated that same-day discharge is possible after radial access even in ACS patients (Bertrand OF. Am Heart J. 2008;156:135-140.)
In the United States there are currently negative financial incentives to discharging patients on the day of PCI, he said, adding that this may soon change.
It All Started with a Cup of Coffee
For Dr. Gilchrist, the practice of same-day discharge began about 10 years ago, when he was having a cup of coffee at the hospital with 2 radial patients after their procedures. “I was telling them I was about ready to go home, and both of them said, ‘Well, we wish we could go home.’ And I said that we keep people overnight after these things . . . . We’re worried about groin bleeding,” he recalled saying before realizing that the groin did not come into play in these cases. “We ended up sending those 2 guys home that day. That was when the lightening bolt hit me that technology had changed.”
“If you’re in good shape, what is the hospital going to offer you? Hospitals are good places to get infections, to get drug errors, or to not get a good night’s sleep,” Dr. Gilchrist pointed out.
He advised that when considering same-day discharge, the most important thing is that patients have a safety net at home, either in terms of living with someone or having good phone access. “We have a nurse practitioner who gets in contact with all our patients the next day and makes sure that they’ve picked up their appropriate prescriptions and understood everything we talked to them about,” Dr. Gilchrist said.
“When you do these radial and outpatient procedures, the patients are really grateful that you did something different that feels a lot better to them. That’s what I’ve found fulfilling. The other thing is, at the end of the day you go home and your patients go home. You don’t have to worry about getting calls in the middle of the night from nurses asking questions, and there’s no paperwork the next day,” he commented. “The next day you can start anew.”
The question of same-day discharge relates to timely concerns about improving efficiency and safety in health care, Dr. Gilchrist noted. “I think it’s important that, unless we want regulators to take away our choices, we should be the ones out on the forefront trying to change things” for the better, he said.
Sources:
1. Gilchrist I, Rhodes D, Zimmerman H. Real-world, same-day transradial PCI patients in the US: Do the guidelines fit practice? Presented at: Society of Cardiovascular Angiography and Interventions 33rd Annual Scientific Sessions; May 5, 2010; San Diego, CA.
2. Hussain Z, Berg R, Hadid M, et al. Cultural change in catherization access: Initiating transradial access at a teaching institution. Presented at: Society of Cardiovascular Angiography and Interventions 33rd Annual Scientific Sessions; May 5, 2010; San Diego, CA.
Disclosures:
- Dr. Gilchrist reports no relevant conflicts of interest.
- Dr. Lim reports having financial ties with Boston Scientific, Bristol-Meyers Squibb, Cordis, Merck/Schering-Plough, sanofi-aventis, St. Jude, and Volcano.
- Dr. Bertrand reports serving as director of the EASY Research and Education Fund in Transradial PCI, supported by Bristol-Meyers Squibb/Sanofi-Aventis, Cordis, GE Healthcare, and the Quebec Heart and Lung Institute Foundation.
Related Stories: