Initial Transradial Learning Curve Not Harmful to Overall PCI Safety

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Demonstrating that implementation of a transradial percutaneous coronary intervention (PCI) program is manageable and does not compromise safety, a South Carolina teaching hospital maintained high procedural success while lowering bleeding and vascular complications during the first year of its transradial learning curve. The results were published online January 16, 2012, ahead of print in the American Journal of Cardiology.

Researchers led by Robert A. Leonardi, MD, of the Medical University of South Carolina (Charleston, SC), analyzed the results of 693 transfemoral PCI procedures performed from July 15, 2008, to June 30, 2009 (year 1), at their institution. They then compared them with 673 PCI procedures (193 transradial; 28.7%) performed from July 1, 2009, through June 30, 2010 (year 2), when the femoral-only center starting transitioning to a transradial-default approach.

None of the involved physicians had any significant previous experience with transradial procedures, and formal training was not part of the transition. Instead, clinicians’ learning was self-directed, and there was no official transition to transradial access. Rather, attending cardiologists were encouraged at the beginning of the study period to start performing transradial procedures, which were recommended except in patients with inadequate Allen tests and/or Barbeau grade D perfusion by plethysmography.

Transition Goes Well

The transradial approach was not mandated, and the final decision between transradial or transfemoral access was left to the attending cardiologist. There were no major bleeding or vascular complications in any of the transradial patients who received PCI during year 2. In addition, overall bleeding and vascular complications decreased in the second year, while procedural success, predischarge mortality, and length of stay remained steady (table 1).

Table 1. Outcomes After Implementation of Transradial PCI Program

Transradial procedures in year 2 were performed by 13 different cardiology fellows and 9 different attending cardiologists, none of whom had routinely performed transradial PCI previously. Nearly all transradial procedures were completed through the right radial artery, and the rate of conversion from transradial to transfemoral access was 1.5%. In addition, while procedures completed during year 2 required slightly longer fluoroscopy time, procedure duration and contrast volume were similar to those during the first year (table 2).

Table 2. Procedural Characteristics

There were no cases of symptomatic radial arterial occlusion, and since postprocedure screening examinations are not performed at the Medical University of South Carolina, the incidence of asymptomatic radial arterial occlusion in the current study cohort is unknown. Several cases of radial arterial spasm did occur periprocedurally, but all were resolved with vasodilators and/or additional sedative medications.

The study authors note that despite the growing global popularity of the transradial approach, the method comprises only about 1.3% of all US PCI procedures. Reasons for US clinicians’ reluctance to adopt the transradial approach, they observe, traditionally include:

• Familiarity with the transfemoral approach
• Concern for longer procedure times and increased radiation exposure
• Substantial learning curve for the transradial approach
• Decreased PCI safety with the establishment of a transradial program

However, Dr. Leonardi and colleagues write, the current study helps debunk at least some of these perceptions. “These data demonstrate that [transradial] programs for coronary arteriography and PCI can be established at United States teaching hospitals with an immediate improvement in PCI safety and the potential for far-reaching improvement in PCI safety as graduating trainees continue to use the [transradial] approach,” they observe.

The Courage to Change

James Tift Mann III, MD, of Wake Heart and Vascular Associates (Raleigh, NC), called the data “gratifying,” particularly since they come from a teaching hospital. “Over the past decade, we’ve gotten enough data to warrant adoption of the transradial technique,” he told TCTMD in a telephone interview. “And the only way we’re going to get the incidence of radial access higher in the United States is to get it taught at teaching institutions.”

Dr. Mann noted that the South Carolina institution’s experience is not unique. “I can list 8 or 10 other teaching institutions that’ve had the same experience,” he said. “It’s just a matter of believing the data regarding transradial and then having the courage to make the change. Listen, it’s very difficult to be a cath lab director who has to learn a new technique and then teach it. I understand the reticence to do that, but now that the data are here, I hope more institutions will continue to follow this lead.”

Dr. Mann noted that the “self-directed” learning mentioned in the study doubtless refers to clinicians having attended some of the many radial courses available around the country, including live, case-based conferences and simulation sessions. What will mark an important step forward, he added, is when such training becomes a formal part of fellowship programs. “Absolutely, that’s ultimately our goal,” Dr. Mann said. “I think it should be a routine part of the training program of every institution.”

Radial Occlusion Monitoring Key

He also delivered a critique of the paper in that the researchers did not routinely check for radial occlusions, using only symptomatic cases as an endpoint. “This is important because if you have a 5 to 10% incidence, they’re all going to be asymptomatic,” he said. “But if you’re incidence is that high, institutions should document that and make changes in their technique accordingly. Particularly in institutions new to transradial, they must routinely do reverse Allen tests to document the incidence of radial occlusion.”

The reason routine monitoring is important, he continued, is that ulnar compression can prevent or reduce the incidence of radial occlusion if it is applied quickly after the procedure.

Another point worth noting, Dr. Mann added, is that the vast majority of patients included in the study were stable. “The next step in the United States is being comfortable doing emergencies,” he said. “The most compelling data regarding the benefit of the transradial approach is in STEMI, so the benefit of this training program is that hopefully they will begin to do more emergency cases where we really do see a tremendous benefit from going transradial.”

Overall, he said, in terms of advancing the spread of the transradial approach in the United States, the data represent “a baby step, but we’re making progress.”

 

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Source:
Leonardi RA, Townsend JC, Bonnema DD, et al. Comparison of percutaneous coronary intervention safety before and during the establishment of a transradial program at a teaching hospital. Am J Cardiol. 2012;Epub ahead of print.

 

 

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