Article preview from Medtech Insight - March, 2010
If technology changes and clinical outcomes assert their influence over standard protocols, an increasing number of Americans patients will undergo coronary angioplasty through the radial artery in their wrist, not the femoral artery in their groin. As studies are beginning to portray more clearly, those patients are likely to be more comfortable postprocedure, exhibit less bleeding, and recover more quickly than patients treated treated with the traditional femoral approach.
Radial Approach to Angioplasty Gaining Momentum
Article preview from Medtech Insight - March, 2010
After Bill Clinton was rushed to a New York hospital earlier this year with chest "discomfort," a look at his angiogram quickly convinced his cardiologist at New York-Presbyterian Hospital that the former president would require a coronary angioplasty procedure. In the cath lab that day, physicians threaded a balloon catheter through the femoral artery and into the heart of their famous patient, checked the angiogram, inserted a pair of coronary stents, and then declared their work finished. The course of action was not unlike that performed on an estimated one million US patients each year.
But if technology changes and clinical outcomes assert their influence over standard protocols—as they often do over time—an increasing number of future American patients will undergo that same procedure with one notable exception: their doctor will utilize the radial artery in the patient's wrist and cast aside the traditional femoral artery approach in the groin to wind that life-saving technology into the vessels feeding the heart. As studies are beginning to portray more clearly, those patients are likely to be more comfortable postprocedure, exhibit less bleeding, and move even faster on to recovery than did Mr. Clinton, who returned to work within a few days of his stenting procedure.
If present trends continue, and there are strong indications they will, within a few short years Americans who undergo percutaneous coronary intervention (PCI) procedures may increasingly find that this catheter-based interventional procedure is performed via the transradial approach rather than the femoral method that has dominated the field for many years.
US Radial Procedures on the Rise; Federal Mandate in Sight?Starting with a modest 1.5% slice of the volume of catheter-based procedures through the radial artery only a few years ago (according to a 2008 report in the Journal of the American College of Cardiology), the rate of radial artery procedures has jumped to as high as 5% in the US, according to estimates presented at the 2010 International Symposium on Endovascular Therapies (ISET), held recently in Hollywood, Florida. The radial approach is used far more commonly in Europe and elsewhere outside the US, but despite the fact that Mr. Clinton's doctor chose the more traditional course of action, physicians and payors in the US are finding it increasingly difficult to ignore the safety, cost, and patient comfort advantages offered by the radial approach. The movement is gaining steam with US regulators as well, who are attracted by the lower cost of a radial approach (including a reduced average length-of-stay), a major reason the federal government is considering mandating the procedure for Medicare patients, when appropriate, as a cost-cutting measure.
Getting Physicians on BoardIn the near term it appears the only obstacles standing in the way of even wider use of the radial artery in the US are operator training and physician acceptance. "Once the younger doctors begin to come into the profession, you will see the procedure spread quickly," says Miami-based interventional cardiologist Ramon Quesada, MD, a leading proponent of the radial approach. "You can do all types of interventions with the radial artery, just the same as with the femoral artery. The radial approach is not a mystery. It's something we can all do. You just have to get familiar with the catheters."
Quesada cautioned that the radial approach is not for "hobbyists," or for physicians who wish to try the procedure on an occasional basis. Says Quesada, "Once you begin performing the procedure you must commit to performing it full time. I did about 50 cases and realized that this is what I am going to do. The radial approach is my preferred approach for STEMI (ST elevation myocardial infarction) because the patient doesn't bleed. You're finished. You go home, and you're done. The radial approach gives a 50% reduction in complications and it is very comfortable for the patient."
Compelling Clinical OutcomesQuesada's assertions are backed by recent clinical studies, including the 410-patient RAPTOR (Radial Access Versus Conventional Femoral Puncture: Outcome and Resource Effectiveness in a Daily Routine), a prospective, randomized, single-center trial reported last fall at the American Heart Association Scientific Sessions in Orlando, FL. The study found that experienced operators should have little trouble making the switch to the radial artery from the femoral, a change that could trim costs, reduce pain, promote safety, and do it with no resulting drop-off in quality or patient outcomes. Quesada told Medtech Insight he performs all his chronic total occlusion (CTO) procedures via the radial approach.
Curt Werner
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